Billing for Your Services: Common Q and A’s
by Legal & Regulatory Affairs, Federal Regulatory Affairs and Communications Staff
Whether you are wondering how to bill for a health and behavior assessment or when you may charge an out-of-network rate, it pays to know billing basics. This article addresses several matters that practitioners commonly raise with staff for the APA Practice Organization.
Q: When billing Medicare and private insurers for psychotherapy services, do I count only the time that I actually see the client, or can I include the time I spend writing up my notes after the session ends?
A: Because the Current Procedural Terminology (CPT) code descriptors for psychotherapy contain the phrase "face-to-face with the patient," you may only bill for time that you spend with the client. Report writing is considered an integral part of the service and is reflected in the payment level assigned to the codes.
Q: What type of assessment should I bill for if I am evaluating a client who has both physical and mental health problems?
A: It depends on the predominant service you provided to the client and which CPT code best describes that service. If the majority of the time spent with the client related to a physical health problem rather than a mental health problem, you should bill for an initial health and behavior assessment or a reassessment (see additional information about the health and behavior assessment and intervention CPT codes). If you spent the majority of the time assessing a client's mental health problem, you should bill for a psychiatric diagnostic interview or a psychological assessment.
Because not all private insurance plans cover the health and behavior codes, psychologists treating clients with private insurance are advised to confirm coverage with the carrier or plan administrator.
Q: I am new to a managed care organization (MCO) panel. How can I find out what billing procedures to use when submitting claims to the company?
A: The main places to look for guidance are your provider contract, the company's provider manual and the "provider" section of the company's website. The latter two sources usually indicate how to contact the company if you have further questions.
Q: My client is a subscriber to an MCO plan where I participate on the provider panel. The client has decided to pay privately and not submit claims to the MCO. If she later changes her mind and submits claims to the MCO, is there any risk that I as a panel provider will have to reduce my bill to the lower panel rate?
A: In most cases, the answer is yes. Contracts frequently state that psychologists cannot bill an MCO subscriber for more than the contract rate. In some situations, if a client or a client's spouse decides to submit claims to an insurance company after paying privately, the psychologist may be required to reimburse the client for the amount that exceeds the covered panel rate.
Q: I have a new client who is a subscriber to one of several plans offered by an MCO. Though affiliated with the MCO, I don't think I'm on the provider panel for that particular plan. Will I Get paid the higher out-of-network rate if I'm not on that panel?
A: When an MCO has more than one provider panel, psychologists often have difficulty determining whether or not they are on a particular panel. If you are in this situation, first check your provider contract. It may indicate that you are on certain panels, or it may state that the MCO has the right to determine what panels you are on. Even if the MCO assigned you to certain panels initially, it may have sent you a contract addendum that adds to your panel assignments.
You may communicate with your network manager or other appropriate contact with the MCO to verify your panel participation status. It may be advisable to confirm in writing —for example, by e-mail— any information that is communicated verbally.
If you determine that you are not on the panel for your new client's plan, you should be able to be paid the higher out-of-network rate.
If you find that the MCO considers you as participating on all panels, check your state insurance laws. Several states restrict MCOs' ability to require providers to participate on all panels.
Q: Will submitting claims electronically trigger the Health Insurance Portability and Accountability Act (HIPAA)?
A: If you, or a billing service or clearinghouse acting on your behalf, electronically transmit "protected health information" as defined by HIPAA in connection with health care claims, you will trigger compliance requirements related to HIPAA.
Q: What steps must I take in order to treat Medicare beneficiaries and bill Medicare for my services?A: Medicare will not pay for the services you provide to a Medicare beneficiary unless you have a Medicare provider number. You need to apply for a provider number through the local Medicare carrier in your area.
You can find the local carrier's contact information by going to the website for the Centers for Medicare and Medicaid Services. Scroll down the menu on the left and click on "Contacts." Then use the pull-down menus to indicate the state in which you are practicing and select "Carrier (Part B)" as the type of organization.