Getting Credentialed with Insurance Companies as You Grow Your Practice by Ferrella March

0:00Alright. We're gonna go ahead and get started for the, respect to those individuals who were on time. And if other people join us, we will see that on the participants. We did introduce Ferela, on the actual invitation, but I wanna just say a couple personal things. Number one, she likes us so much. She actually referred her son, who is also now in the masters of counseling. She had a twenty year career, if you will, serving the state of Oklahoma. And this is a whole new career for her, and she's just been so excited to do it. And it wasn't it was a long journey, but as you know who are counselors and PsyD folks, it's worth it. And, she graduated with her master in science in, in what year?

0:50Let's see. You were in 2021. 2021. And she has very definitely been one of my most valuable alumni advisory board folks. And for her you you that are on here, I'm always looking to add more alumni advisory folks. So, Janet, if you or anybody else who signs up on this would be interested in that, I would love to talk to you offline after this. So I am very excited that Pharrell jumped forward as an alumni advisory board person to give her experiences on getting credentialed with insurance companies to grow her practice, especially in the field of mental health. So take it away, miss Farella, and thanks for your gift of time. Alright. Thank you, Michelle. Well, good evening, everyone. I'm glad you could join me tonight.

1:37Tonight, I'm going to be giving a very riveting talk on insurance. I know most of you wanna spend, 08:00 or whatever time it is, wherever you are, thinking about insurance. Well, I thought the same thing, but I have really grown to I have really I've really grown to enjoy, learning more about insurance. And really quite honestly, as a as a sole provider, I really need to know as much as I can. So I'm hoping to share a little bit of that with you tonight. And let's see here. There we go. So as Michelle said that I am a DMU alumni, and and I am currently serving on the DMU advisory board. So although I did graduate in 2021, I have been going to DMU since 2017. I was attending DMU part time while I was finishing out my career with the state of Oklahoma in the environmental field.

2:47So it was a complete, jump and shift into a completely new field for me. I completed my internship at Catholic Charities with the Diocese of Oklahoma City, and I completed my candidacy at NorthCare, which is a certified community bay behavioral health clinic. I was part of a rapid response team helping clients who were stepping down from hospitalization due to suicidal and homicidal ideation. And then in 2024, I decided to open my own practice. And so here I am, and I've learned a lot this past year about insurance. So, hopefully, I'm gonna be able to shed some light on the, business of insurance. Just a disclaimer. The information that I'm going to provide tonight may vary depending on individual insurance company requirements.

3:38Any allowable amounts provided are estimates and subject to change. And, additionally, insurance companies and contact information may vary across states. I wanted to just put this slide up because I think it's important when you're talking in acronyms, to be able to provide an explanation of what these things mean when people are tuning in to a webinar or presentation. So these are some common ones. Maybe I don't use all of these tonight, but you will see these as you deal with insurance companies. The ones that I think would be beneficial for you to know for tonight for for the purpose of tonight's presentation is NPI, which is the national provider identifier, and cash, which is a provider data portal.

4:28So tonight, we will be exploring benefits and challenges of taking insurance. We will learn about credentialing requirements. We will explore workflow from provider, which is us, to the payer, and we'll also explore some ethical considerations. And I have, actually an example that happened to me recently, so I wanna share that with you. And then I also have some helpful links, and I would be happy to send those out to you if you I I don't know if you're able to get those from this presentation, but I would happy I would be happy to send those out to you separately. So in the mental health field, we have the ability to either accept insurance or accept private pay. Just as medical costs can start to pile up, so can the cost of mental health.

5:17Some people are able to afford private pay, but many people rely on insurance to help mitigate cost. Insurance can help increase your client load and allow you to help serve a more diverse population. Accepting insurance can help reduce financial burden for clients, and it can also increase cash flow and create a more stable income for you, for the provider. Well, there are also some challenges to accepting insurance. For example, the claim submission process can be very difficult to navigate. And I I subscribe to a software. It's called therapy appointment, which, helps me to send the claim out to to the clearing house, which we'll discuss in just a little bit. Well, no one likes denials, and this is a this is a reality when you're dealing with insurance.

6:10Sometimes your claim is denied. Well, that requires, you have to go back. Maybe you have to do some additional work. And so nobody likes denials, but it is a reality of accepting insurance. Some insurances, require authorization, so this can also involve extra paperwork. And if you take insurance, you are subject to audits, especially Medicare and Medicaid. Some insurance companies may be slow to reimburse, and this is what I'll talk about a little bit later too, And it's also an ethical consideration. Also, with insurance companies, they they may have multiple payers including third parties. So it just gets it just gets very complicated, in the end. It's just good to know what the workflow is, and the more you can know about insurance, the better.

7:03So if you were to weigh the benefits and challenges, it might look like the challenges, you know, the cons outweigh the benefits. However, you also have to consider the weight of each of the pros and cons. So for example, one pro may be equivalent to two cons. So you just kinda have to weigh that out as you're discerning whether or not you wanna take insurance. Okay. So let's get into the process of credentialing, but first things first. Whether you're going into private practice or not, you will have to obtain appropriate licensure in your state. This is regardless of whether you're going into private practice. Just if you're practicing, you're gonna have to, get your license. If you plan to go into private practice, then you will need to also obtain an EIN number.

7:54This is a federal ID number. You will also have to obtain a national provider identifier number. So this is mostly for billing purposes. If you already work for an agency, then more than likely, you have applied for an individual MPI number. Your agency, on the other hand, has applied for a group NPI number. So the important thing is when you do go into private practice, especially if you're transitioning from an agency to private practice, you'll wanna make sure that you update your NPI. I happen to have both because I set my business up as an s corp, so that allows me to expand later on down the road. You will also need to complete a uniform provider data, UPD, and this is done through Cash ProView.

8:48And this is this is actually key, and we're gonna talk about this in just a moment. So now I'm gonna go over just some general requirements for credentialing. So you can go ahead and get the ball rolling, and I would suggest getting the ball rolling and rolling just as quickly as you can. If you are working for an agency, just make sure that you're not violating their policy. So just make sure that you know, you don't want to, you know, end your employment before you're ready. So I would go ahead and update your CV or your resume. Make sure that you have current copies of all certifications and license for each state and any specialties that you might have obtained. Make sure that you have updated copies of your malpractice insurance and malpractice claims information, and make sure that all of your tax information is updated.

9:48Something new this year or actually in 2024 is you are required to register with the Financial Crimes Enforcement Network. Is that true in all states, Ferella? I believe that is true in all states because that is not yet a federal requirement. Yes. And that and we will welcome your questions at the end, by the way, but that was one that I know. It's a little different in some states, but I thought that was everywhere. I just read that recently. Thank you. Mhmm. Yes. Of course. So there are some things that you just wanna make sure that you're gonna have that you have access to before you start the credentialing process. Again, your updated national provider identifier number. Make sure it's updated, especially if you worked at an agency prior to going into private practice.

10:41Make sure you have your Social Security number, your EIN number, your completed w nine. And for EFT enrollment and claims payment, you will need to have a letter from the bank, and that's a letter just stating basically, proving that you have a checking account at that bank and also a voided check. You'll also want to make sure that you have a letter from your licensing board that you are in good standing. To begin the credentialing process, you will need to request an application from the insurance company for behavioral health. Keep in mind, credentialing is based on cert certificates, licensure, registration to practice, academic background and training, and also assessment of professional competence and conduct.

11:42And all of this information is part of your cash profile, which most insurance companies will access. It is important that you maintain your cash profile, and you will actually have to attest every every three months. Additional information may also be required like rosters and contracts. Contracts are required for all insurance companies. Some insurance companies require what rosters even if you're not a group. And I wanna say something also about the cat your cash profile. This is the thing that has all of your information in it. And since most of the insurance companies will access that, It's important that you get started on that and that it's accurate. It does take a little while to complete.

12:41So there are considerations when choosing which insurance companies to accept. The important thing to remember is you don't have to accept all insurance. And I would encourage you to do your research and choose insurance companies that are in alignment with your needs. Some considerations include current reimbursement rates, the popularity of the insurance company, whether or not the authorization process is easy, hassle free, And do does the insurance company allow unlimited visits, or do you have a limited number of visits that you're able to provide? And, also, you want to consider how how quick turnaround is for payment. So this is a copy of or an example of different insurance rates. These are just some of the the popular, insurance companies that, that I'm credentialed with.

13:46But I wanted to take a look at Blue Cross Blue Shield, for example, and I've circled that in red. And, again, these are estimated rates, so these, you know, don't use these for anything. They're just estimated rates, and they could easily change. But let's take a look at Blue Cross Blue Shield. And so over on the left, you'll see, a sample provider fee is, like, a $175. You know, whatever your provider fee is, maybe it's a 150, maybe it's 180. The maximum that you're gonna get for an intake is gonna be $124.75. For a fifty three to sixty minute session, then you will receive $105.33. And that's so that that's the allowable rate. So when establishing your rate, you wanna make sure that it's more than, like, the allowable rate for insurance companies because that's the maximum that you're going to get.

14:49Get. So I wanna shift for just a moment and talk about Medicare, specifically, since the credentialing process is just a little bit trickier. So effective 01/01/2024, LPCs were able to accept Medicare. And prior to that, only psychologists and licensed clinical social workers were able to accept Medicare. So this is pretty big because this changes this this change actually opens the door for more of our older population to be seen for their mental health needs. So let's take a look at what we have here. So when you click on the link that the cms.gov link, it's gonna take you to, a page like what you see here on the screen. So just follow these steps. And if you get stuck, feel free to reach out to your MAC, which is the Medicare administrative contractor.

15:43They're actually here to help you. Once you get into the enrollment application, this is the part that takes a little while, so be patient. If you know somebody that has experience with Medicare enrollment, then I would definitely reach out to them. So just in general, I wanted to talk about what Medicare what what the whole, like, process looks like with Medicare, once you get credentialed. So clients generally have to meet a $257 deductible, and many people have a secondary insurance that will pay for the remaining $22.51. So it's a $112.55 per session. That's for a sixty minute session, and then that doesn't pay for it all. The $22.51 is what is left over. If they don't have a secondary insurance, then they're responsible for that payment.

16:39Well, the good news is for us, for the provider, is that we don't have to be credentialed with the secondary insurance company in order to receive payment. And Medicare, if it's traditional Medicare, will forward that claim on to the secondary insurance company. So it just means a lot less paperwork for you, and you don't have to file the claim with the secondary insurance company unless it's not traditional Medicare. And then that's a little bit of a different story. So it can be very confusing for the provider and the client when they enroll in their in other Medicare plans, so not traditional Medicare, which are really which are really which is really like Medicare in disguise. So as a provider, you wanna make sure that you are in network.

17:26And I'll give you an example. This happened to me recently. I had a client with Medicare Advantage through UnitedHealthcare. Although I was in network with UnitedHealthcare, I was not in network with the Medicare Advantage Plan. So it it was an easy enough fix, but I definitely was kinda caught off guard. So that would be what I would suggest to you is just making sure that you know the difference between traditional Medicare and then other Medicare plans. You know, Medicare in disguise. But you know what? There are other masters of disguise, and this includes Medicaid. And I don't know what it's like in your state, but in Oklahoma, Medicaid now uses third party insurance companies like Aetna and Humana.

18:16And even though I am credentialed with Aetna, I'm not a Medicaid provider, so I can't accept that insurance or I can't, you know, help that client with that insurance. To become a Medicaid provider, you have to sign a separate contract and then agree to certain requirements. So okay. Now that you are credentialed, it is important to understand how the claim submission process works. The more you know about this, the less stress you're going to have. So let's take a look at this this flowchart. So from you, the provider, the claim goes to a clearinghouse, and we'll talk about clearinghouses here in just a minute. From there, the claim is sent to various insurance companies. And, included in here I also included Avedi and PECOS.

19:14And the reason why is because these are considered, they're multi payer provider portals, and they manage claims for several insurance companies or payers. PECOS is specific to Medicare. So on the bottom layer, you'll see payer. Well, some insurances insurance in some insurance companies use a third party payer. So for example, Optum Financial is a third party payer, and they manage payments for, in Oklahoma, Health Choice, and then probably all over the nation, VA Community Care Network and UnitedHealthcare. VA Community Care Network is actually kind of a cool thing. So this is the in the this is, part of the VA system. And if they can't accommodate the mental health needs of a of a of a patient or of a client, then they are able to send them or refer them out to the community.

20:14And so that's really that's really cool and a great way to be able to to serve their to to serve their patients. So let's talk about what a clearinghouse is. For example, I use OfficeAlly. There are different clearinghouses out there, and it acts as an intermediary between health care providers and insurance companies or the payer. It ensures it it ensures claims meet industry standards and payer specific requirements. A clearinghouse allows for submission of claims in one location, and therefore, it increases the accurate it it increases accurate submission rates. A clearinghouse also helps to reduce claim rejections and helps with timely reimbursements. So how does all of this work? So this this is an example of what a clearinghouse can do.

21:14So it starts with claim scrubbing, and claim scrubbing is a process of reviewing and validating medical claims that includes mental health claims before they are submitted to insurance payers for reimbursement. The process ensures that claims are accurate, complete, and in compliance with the specific requirements of each of the payers or the insurance companies. The process helps ensure that medical practices, including us, including mental health providers, receive timely and accurate payments. So then let's take a look at adjudication. Claim adjudication is the insurance company's review process for the claims you submit. So when you send in a claim for services provided to a client, the insurer doesn't just automatically pay it.

22:05They don't just say, well, you sent in the claim. We're just gonna pay it. Instead, they take a closer look to decide whether to approve it, deny it, or maybe they need to request additional information. So what the clearinghouse does, it kind of does all of this prep work ahead of time. So once it goes to the payer, then the adjudication process goes a lot smoother, and it reduces the risk of denials. So the other benefit of a clearinghouse is that well, one, it saves you time. So instead of going to each website for insurance companies, you can view responses and track claims in only one place, and this saves a lot of time. A clearinghouse can also reduce errors, prevent denials, and it helps you to get paid faster.

22:56And let's face it. When you're in private practice, you wanna keep that that cash flow coming. So the efficiency of the clearinghouse also allows you to spend more time with your clients instead of dealing with claims and billing. So that's really what it's about, isn't it? We wanna make room for our clients. We don't wanna spend all of our time doing paperwork, dealing with claims, dealing with denials. We wanna spend time with our clients. That's why we're doing what we're doing. A clearinghouse identifies claim errors and and tools to fix the problem before the adjudication process. So it in it improves your cash flow because you're gonna deal with fewer errors, and it increases and it just makes for quicker payments.

23:48A clearinghouse stays ahead of frequent changes that occur in the insurance industry. And this is pretty important because that's another thing too. We don't have time to stay up on all of the different changes that may occur in the insurance industry, and there are a lot. It it changes pretty frequently. And then, of course, the clearinghouse can generate useful reports that increase an understanding of the billing process and can highlight opportunities for improvement. And now let's talk about ethical considerations that might come up from time to time when accepting insurances or when accepting insurance. So best practice is to be proactive and prepare for the unforeseen. Be active in planning and getting clients to services else elsewhere if needed and specify insurance changes or lack of reimbursement in your informed consent, including a disclaimer about what transitioning might look like.

24:55For example, if something happens and insurance will not reimburse, then a client can pay out of pocket and send in their claims directly to their insurance company, or they can be referred out to another provider. So you will need to decide as the provider if you wanna continue taking the insurance. And but remember that you are under contract to accept clients, and, also, it's not ethical just to abandon your clients. So you can't just say, well, the insurance isn't paying, so I'm just not gonna see you. And that's why you need to be prepared and make sure that that that make sure that you have that discussion with your client. If you choose to continue taking a specific insurance, then you may want to limit your caseload for that insurance.

25:41You can become credentialed with many insurance companies. It doesn't have to be just one or two, so that way your eggs are not all in one basket. This dilemma is most common when insurance companies undergo a transition to another payer. And so I'm gonna tell you, I experienced this very recently, and I had a an insurance company that was not reimbursing me, since January. They they did finally pay, but it was it was not until March, that I received any kind of reimbursement from this insurance company. And this was primarily because they were they were transitioning from one company to or one payer to another. And in that process, they just weren't able to process all of the claims. But they did finally pay.

26:35And I did continue to see my clients, but it did affect about 20% of my caseload and and, therefore, about 20% of my cash flow. So getting credential can be a lot. No doubt about it. I would recommend that you get help from designated staff. Many agencies and groups will have staff that can work on credentialing. If you are doing it alone, then reach out to the insurance companies. They will help you. They'll be happy to help you. And be intentional when choosing insurance companies. Consider quality over quantity. Understanding insurance workflow can also be helpful and can assist you in making ethical decisions. So be prepared for the unforeseen. When it comes to insurance, be proactive rather than reactive.

27:38So I just wanted to acknowledge a couple of people. Maricar is our account specialist and credentialing liaison, and she has helped me immensely with the credentialing process. She also helps me with my billing. And then also Amy Shipman, who is my old boss at Catholic excuse me, at Catholic Charities, and she helped me work through the ethical considerations. K. And this is the these are the helpful links that I think most of these would be helpful for you. There's some that are, state specific. But if you would like a copy of this, I can get that to you. Well, actually, I will probably since we're recording this, Pharrell, I'll be able to send it to them. Okay. And if you all have any specific questions, please put those in the chat.

28:31I just wanna say thank you because I've talked to people who graduate and they, you know, they hear these kind of stories, but yet if you're a practitioner on your own, yes, indeed, some places will only take cash. But as we know, that shuts out a lot of individuals who could indeed use counseling. So I think this will be very valuable. I'm gonna send it up line to counseling and see if they wanna if they wanna use it at the end of maybe when a person's about to go out and be licensed and open their practice. Do either of you who are on the call have any questions you'd like to put in the chat? That was so well done, Pharrella. Thank you. Thank you. Yes. And this is my contact information. If anyone needs to get ahold of me, feel free to reach out to me either through email or my phone number is there as well.

29:18(405) 314-3757. K. Janet says one of the mistakes I made was to transition to private practice before I was credentialed. So that was a learning curve for her, it sounds like. Yes. And, yeah, I would agree. I and and and the reason I said, you know, check with your policy if you are working for an agency or, you know, well, an agency. So, like, when I was working for Northcare, because I I did have a cash profile because I had set one up because I started credentialing with them. But then I transitioned out of Northcare to private practice, now my cash profile has them as the rendering agency. And so that was a little bit of a mess. I had to make sure that that was updated. But, also, there's a policy that they have that you can't, like, go into private practice while working for them.

30:18So I wanted to make sure that I was being ethical there. So I kind of you know, I had a end date, and then I had a start date of, like, you know, fifteen days later. But, I had help going ahead and getting that ball rolling with some of the But, indeed, it takes a while sometimes, doesn't it, Janet? So one of the things that I hope comes from this also is that when I do distribute it to the other people who did sign up, they probably didn't realize it was this late because we have time differences. But I wanna see if there are other subject matter that our alumni can deliver from their their backgrounds, from what has happened to them in the real world after they finally get licensed and they finish everything.

31:04But I do hope that any of you who have any suggestions on that will let me know, and I'll send you a side email. So Maria says, not at this time. We can be private practice in Texas. I am although as an LPC associate, we can only credential with a couple of insurance companies. It doesn't pay to do it as an LPC associate. And, again, it is different everywhere. But let me also give you the fact that we are working a lot closer with the Catholic Psychotherapy Association. In fact, I'm gonna be going to the event in Philadelphia. And there's not a day that goes by that they don't ask for referrals from all over the world. And one of the things that I did, as I think both of you know I know I know Maurice in there.

31:52I'm not sure you are, but we have an alumni directory. And one of the things I'm encouraging people to do is to put in either their website or down in the notes the insurances that they do take because that's very important. Sometimes a referral will come from this person, you know, needs this criteria for treatment, and they need to be able to accept, you know, Blue Cross Blue Shield. So, I definitely want to encourage everyone to do that. So for both of you on this call, and I think when I send this out to the other people who registered or use it for training, I wanna know what other subjects that as an alumni advisory board group that we might be able to, do these kind of webinars. I think the next one might be from another advisory board member named Jerome Placido who wants says he could talk about the IT part and setting up offices and doing those kinds of things.

32:50Because one of the things we wanna continue to do as an alumni association is be present in your life and help you with things that will help you grow your practice and knowledge of Divine Mercy University. Again, thank you so much, Marie and Janet. If you have, any other questions, I'll we'll be happy to answer them. Janet has one that says budgeting, setting rates, cash rates, and sliding scales. So is that a topic that you might like to see discussed in a webinar, Janet? Okay. Well, that's good to know, and I will, follow-up with both of you all tomorrow. And like I say, we'll just get this recording out. That's we have a wonderful communications person online here with us, and they can actually, record this, and we can get it out.

33:46Thank you both for your gift of time. We have about seven or eight that were signed up, but you know how it is at the end of the day of treating customers. And, again, I can't thank you enough, Varela, for for all this. It was a great presentation. Yes. You are welcome. Anytime. I'm glad I could I'm glad I could share some of my experiences. You set the bar real high for the next one who does that. So thanks again. Alright. You're welcome. Have a good night, ladies. Alright. Thank you. Uh-huh. Bye bye.