For those of you, like me, who choose not to work directly with insurance companies, you are considered to be an out-of-network provider.
A mental health provider I will call “John” wrote in asking for clarification about his out-of-network responsibilities . . . .
A new client whose health insurance policy is from out-of-state just sent me a Treatment Request Form from Magellan, and he told me that I am supposed to fill it out and submit it to them.
Is this true? If I don’t accept insurance, I thought that meant I would not have to fill out any insurance-related paperwork?
Please help to clarify if you can.”
One of the perks of being a mental health provider in private practice is that you get to determine what each of your office policies is including those that address if and how you decide to work with insurance and managed care.
Because “John” is an out-of-network provider, he may choose (or choose not)
- to complete insurance claims for his clients;
- to then file those claims for clients;
- to contact insurance companies on behalf of his clients’ claims (after obtaining permission to do so); and,
- to accept payments directly from insurance companies.
Each one of these choices can be made independent of the other choices listed above.
(I no longer choose to work directly with managed care. Here’s a post I wrote explaining why.)
As a mental health provider you are not obligated to complete any form or document from an insurance company unless you have agreed you will do so (typically in the form of a contract).
After being “out of network” for a few years, and having to deal with insurance companies on behalf of my clients, I finally decided to opt out of insurance reimbursement all together. If I state to my client that I am out of network, there is an expectation that I will work on my client’s behalf to be sure benefits are maximized. Unfortunately, this becomes cost-prohibitive. For every hour I spent with a client, I spent that much time with insurance companies following up on requests or telling me that no more sessions would be reimbursed due to a diagnosis that the insurance company felt did not warrant any additional sessions. I finally went fee-for-service and added this to my website:
http://www.mentalhealthonthewebblog.com/rates/
DeeAnna, I’m right there with you! Been there. Done that whole managed care dance! Thank you so much for sharing this link to your explanation of payment. I especially love your explanation concerning sliding scale fees! Brilliant! Just to be clear . . . is this something that you would allow other therapists to use verbatim or just as inspiration? (I’ve had way too many instances of plagarism so I thought you might want to spell this out here:)
Hi Tamara,
Thank you for posting this article. I also enjoyed reading DeeAnna’s explanation regarding payment and reimbursement, etc. I was previously an in-network provider until last year, fully making the transition last fall. What a sigh of relief. As DeeAnna described, I was using so much of my “administrative” time addressing insurance issues (did my own billing) and explaining benefits to clients that I no longer felt like I was in private practice but could have easily secured a job for any of these insurance companies as a service rep. 🙂 I’m thankful to have a thorough understanding of it so I can effectively explain to clients how reimbursement works, however, a true weight was lifted off of me when I made the transition into fee-for-service. My greatest fears were that: 1) the phone would stop ringing / emails stop coming in once I was off the panels and 2) that clients would not be willing to do fee-for-service. I would like to say that neither one of those things ended up happening. Any time outside of sessions now can actually be spent on the more creative aspect of the work I enjoy, reading, researching, developing… and let’s face it, just being home earlier. 🙂 My current approach is simliar to what you and DeeAnn describe, which is being clear with clients that if they would like to pursue reimbursement I will provide them an appropriate receipt of payment but that all correspondence will need to be betwen them and their insurance company. Seems to be working great so far (almost a year).
Hi, Jodi! Welcome to Private Practice from the Inside Out! And, thank you for taking time to share your experience! I believe that as more therapists speak up and ‘fess up that they are choosing to successfully work outside of managed care, other therapists will be able to find their own courage to do the same.
I heard from a therapist just this morning who believes that because she cannot get on preferred provider panels, her practice is doomed to failure. You and me and many other therapists know that that is not the case. I wonder if you would be willing to share how you have been able to successfully make that transition to being a managed-care-free practice . . . . Got any tips to share?
Hi Tamara,
I just saw a recent comment on this post and discovered I never responded to you. Absolutely the information can be used in part or in whole for anyone who finds this explanation useful. Even though I am no longer practicing psychotherapy I have kept this page up for archival purposes. https://havanawellnessstudio.com/rates/
Oops! Sorry for the late reply! Yes- you can take what I have and use it- or change it to suit!
Thanks, DeeAnna!
Hi, Tamara! I’m relatively new to private practice and I’ve found your site to be an invaluable tool along the way. I’ve been combing through your posts under the “Insurance” topic, looking for any mention of how HSAs/FSAs work in light of private practitioners. I am attempting to go the no-insurance route, so I solely accept private-pay clients. How do HSAs and FSAs work in this business model? Do you accept them? What are the logistics associated with this process? I apologize if my question seems obvious – I’ve been searching and searching online and I can’t find a single mention to elucidate the process for if/how therapists can accept HSAs or FSAs. I really appreciate any insight you can give me! Thanks.
Hi, Kristen! It’s so nice to meet you! Thanks for dropping in here to chat!
I believe this post will answer all of your questions. If not, don’t hesitate to drop back in and ask for clarification.
Maximizing your FSA & HSA Qualifying Expenses: Maximizing Your Flexible Spending Account or Health Savings Account
It’s great to meet you, too!
Thanks for the information, but I’m not sure that my questions were answered by that. What I really mean is: how does a therapist go about taking HSAs or FSAs as payment (e.g., Can they be run as credit cards? Give receipt to client? Is there a Superbill that needs to be filled out and given to the client if they pay in this manner?).
If you accept these as forms of payment, I’d love to hear from you how the process works. If not, no worries! I can keep searching around.
Generally you do not need to do anything special to accept HSA/FSA payment. Most of my practice is fee for service. Clients use checks that are associated with their FSA/HSA account. I also have some clients use my receipt (with info needed to submit to insurance if they want) for reimbursement from their HSA/FSA if they do not have checks. I also just started accepting credit cards via Square and it is very easy to do using my iPhone. You do need to call their customer service number to have your account labeled as a health service provider so that it will accept HSA/FSA credit cards. Very easy all around.
Yep, Linda, you are having the same experience that I’ve had.
Thank you for explaining this all so thoroughly so that others can learn from you!
Happy to have you in the Private Practice from the Inside Out community!
Hi I am also in network with two insurance companies and a starting practitioner. Inwas wondering if I wanted to be an “out of network provider,” do I need to call each insurance company and set this up? Or do I solely give the client a receipt and allow them to file claims on their own. I’m a little confused because Aetna told me I needed to fax them some forms to become an out of network provider. Any help would be greatly appreciated !
Hi, Valentina! Welcome to Private Practice from the Inside Out!
Being an “out-of-network” provider means that you didn’t apply and didn’t get accepted to be an “in-network provider” so typically you need to do nothing except provide a receipt to your clients for your professional servcis.
I’ve never heard of a managed care company asking out-of-network providers for any paperwork.
Perhaps you left something off of your receipt that they require – an EIN or NPI number or CPT code or even a diagnosis?
Thank you. Is there a format online that I can use as a receipt?
Hi there, I know this post began a few years ago, but still very relevant! In response to Tamara, I have actually had insurance companies require me to “register” as a “non-provider.” I was wanting to file the claim for the clients as a service. I think the registration is also assuming I am taking the reimbursement directly, which some insurance companies allow you to do, even as an out-of-network provider.
Hi, Karin! Thanks so much for pointing this out!
Yes, it is possible that a company will require this if you choose to file the claim for your client.
In my experience, the way around that is to have the client file her own claim.
Good Morning,
I wanted some insight regarding setting up a tax-id for private practice. Is that something you’ve done, and if so, did you choose to operate as a sole proprietor or LLC?
Thanks,
Cindy
Hi, Cindy! You are asking two very different questions.
Your tax id in private practice is called an Employer Identification Number and you can find out how to get one right here – http://tamarasuttle.com/employer-identification-number-get-yours-now/.
It’s simple and it’s free to do.
However, the business structure that you choose to work under is a decision that should be made after consulting with your accountant and your attorney.
Thank you for clearing this up. I do not fill out forms for my clients. I coach them through how to go about obtaining the forms and give them a customized invoice but I agree, I am not on panels.
Hi,
Love this blog! Always so insightful. I am exploring the idea of getting rid of two insurance companies that I work with- Cigna and BCBS. They both reimburse around $80 but my private fee is $150. Given I live in NYC, I realized seeing 35 patients a week is difficult and exhausting when I am only getting paid $80 per visit AND doing all of the billing, submitting weekly claims to insurance companies, following up etc.
Here’s my fear: the phone will stop ringing and the emails will stop coming in. I am afraid to get off the insurance panels because if I don’t have any clients, I cannot survive (especially in manhattan!) I realized through Psych Today that 99.5% of my inquiries are from clients who have one of the two insurance companies I am in-network with.
Should I wait to see if more private pay or out of network clients contact me? Or should I bite the bullet, take a risk and see where this goes? Thanks!
Hi, Valentina!
Thank you for letting me know that you’re finding what you need here to help you rock your private practice!
Your fear of that the phone will stop ringing and that the new clients will stop coming was my fear, too, but that just didn’t happen.
And, of course, in hindsight, how could it?
There is countless research in the United States of America that says that there are way too few therapists for the amount of mental health needs that exist and the wait to get in to see mental health providers is often unconscionable.
Should you wait to see if more private pay or out of network clients contact you?
Nope.
Should you bit the bullet, take a risk, and see where this goes?
Nope.
You need a plan and you need a safety net.
Here’s How to Disentangle Your Private Practice from Managed Care.
After you read that, let me know if you still have questions.
Valentina, most important of all you need to know that this is do-able.
I have been in pp for about 8 years and have only been part time and only accepting EAP and private pay. I have BCBS that I am a part of but have not posted that I was a part of that group until this week. I have applied to Aetna and Magellen. I did not want to join the insurance groups but I have not been getting the off the chain calls like people are saying that they are receiving. I get EAP, still not as much as I like. my question is how are you guys doing it? How do you get more clients?
Hi, Mamie! Thanks so much for dropping in and asking this question!
I get it all the time.
And, I apologize for the delay in responding – I’ve been traveling for the last week out of the country and had lousy internet connections everywhere I went.
The best way – the only way long term – to get more clients is to have a plan to build relationships with potential clients and referral sources.
I say “have a plan” because if you do not have a plan, then your focus is like a shotgun i.e. all over the place with no depth – and depth is what you need in a relationship in order to not just get seen and known but also liked and trusted.
After all, who is going to refer their family member or best friend or even their clients to you if they don’t trust or even like you?!
It’s also important to remember that not all relationships are equal and not all are going to be useful to you in building a practice – so you want to be particular about where you spend your time, energy, resources, and efforts.
Here’s what’s key to remember – it’s only going to take 3-5 great referral sources for you to keep your practice full and flourishing.
Your job is to identify those key referral sources.
Work into who those might be by taking the time to clearly identify your ideal client and what it is that makes it different to work with you.
This is the pre-work that will then enable you to identify who and where your key referral sources are likely to be.
Most therapists who struggle in private practice either didn’t know to do these things in this order OR they knew to do them but for whatever reason didn’t do them.
I suggest you give yourself mini-deadlines to accomplish each of these steps and make the commitment to reach out for support from a colleague or a coach if you don’t meet your own deadlines.
Mamie, I’m not sure what “off-the-chain calls” might be for you and, if you’ve followed my blog here, you already know that leaving managed care behind was the smartest choice I’ve made in private practice.
But, either way – in network or out-of-network – you can thrive in private practice.
If I can help in any way, feel free to reach out!
I’m happy to help you thrive!
Hi,
I’m an out-of-network provider and I give my clients a statement that includes my EIN, NPI number, and CPT codes. They can then use the statement to file a claim with their insurance companies to be reimbursed for what they’ve paid me. I recently had a client tell me his insurance company is requesting a W9 from me in order to process his claim. Have you ever heard of that?
Thanks for your thoughts,
Kim
Nope. I have not, Kim.
And, frankly, I choose not to interact directly with insurance and managed care companies – and include that policy in my informed consent process.
To date, I have not had a client’s insurance company refuse to reimburse without having that information.
A W-9 implies a financial relationship between you and an insurance company – Does that relationship exist?
If not, there is no need that I am aware of.
Hi Tamara. Thank you for your great article on an important topic! I have been in the process of terminating my insurance contracts for a couple of years. I feel great about it for many of the same reasons you have stated here. One thing I am confused about however: if I submit super bills to my clients, don’t insurance companies still have the right to audit my notes even if I am not under contract with them? If you could provide clarification on this it would be much appreciated. Thank you! Meaghan
Meaghan, I’m not an attorney so please know that if you are asking about legal rights, I can share my understanding and experience but you will still need to seek out an attorney’s opinion in your own jurisdiction to know for sure.
My understanding though is that if a mental health professional has not entered into a contractual agreement with anyone (insurance company or client) concerning such matters, we are not then obligated legally to provide access to those notes.
Nor are we able to choose to provide access without the (adult) client’s fully informed permission to do so.
As an out-of-network (OON) provider who has provided superbills to clients for decades, I have never had my notes requested by an insurance company one time.
However, I have spoken to other therapists who have been faced with that request and I understand that all have declined (with full support of their clients) without incident.