benefit verification headaches

End Benefit Verification Headaches!

The New Year means clients change insurance plans. Or the same plan updates benefits. And so the yearly benefit verification headaches begin again!

The first quarter of every calendar year is a hamster wheel. Submitting, claims rejecting because policies are cancelled. Getting new policy information, verifying those benefits, notifying clients of new benefits, resubmitting under new policies. Often, all that work results in getting claims applied to deductibles for the next 120 days – or even longer. And then it’s back to the client to collect the fees. Exhausting!

Especially if you do it all by yourself in addition to psychotherapy!

Is there a way to end benefit verification headaches?!

I think so. My answer might surprise people who think I’m going to talk about billing: I believe the answer is a clinical one. It’s rooted in some basic therapeutic concepts:

  • Triangulation
  • Boundaries
  • Empowerment

Triangulation

The triangle of client – clinician – insurance is very real. And toxic to at least two points of that triangle. We all know why.

But, when considering benefit verification, I first think about what is the clinician’s role?

Well…treatment. Anything else?

When you’re in private practice, in addition to quality care for clients, you owe it to yourself to ensure that your business is profitable.

More than ever before, if you’re not collecting something at the time of service – consider doing so! Once clients leave your office -or close that telehealth app- your chances of receiving the money they owe you significantly decreases.

Claims turnaround times slow down in January. Every year. Commercial payers have to load new plans, or new benefit profiles. Often there’s new programming that has to be done to capture new CPT coding or modifiers, as well as updated reimbursement policies, federal and/or state laws.  

(You’ll need money from clients while you wait for money from insurance!)

Because of slow payment, if you participate with insurance networks, verifying benefits at the New Year gives you at least some idea of what to collect from your client. At least in theory.

In practice, what we get is a benefit verification disclaimer – and it doesn’t matter whether you’re verifying via phone call, payer portal, Availity, or your clearinghouse.

This calls into question the purpose of our benefit verification headaches. Ask yourself your real purpose in verifying benefits. A task this frustrating and time-consuming must have a purpose. Is the verification really to get an estimate of how much to collect at the first few sessions?

Or is it because you think it’s your responsibility to inform the client what they’ll owe?

Triangulation with insurers happens when there’s misalignment of expectations about who’s responsible to determine benefits. It begins with the best of innocent motives. Therapists are caring people who want to help their clients access and be able to afford mental health treatment. It’s admirable – but when benefits are misquoted by a clinician, it risks damaging a therapeutic alliance – just as it’s being built.

Recent events have shown all of us in a very dramatic way just how much anger there is at insurance companies. The cost of policies keeps rising and rising, while the benefits become ever more skimpy. Clients can’t typically show their anger to those who truly deserve it – the insurance company. A faceless entity over which they have no control.

Meanwhile, therapists have challenging jobs, creating safe spaces for clients to work out trauma, emotional pain, and take their first tentative steps toward healthier ways of coping.

If you quote benefits and turn out to be wrong, is it in your insurance contract to act as a lightning rod for your client’s anger at their insurance carrier?

Of course not. So…where do the boundaries really lie?

Boundaries

Let’s go back to the potential desired outcomes of engaging in benefit verification headaches. It seems to me as if these goals lie along a spectrum, rather than being separate. Nor is it a linear spectrum – the way I see it, both the therapist’s needs and the client’s needs must be met.

The goals closest to the needs of the therapist are easier to achieve. Therapists don’t necessarily require an exact benefit summary. As long as you know that the client is eligible, and that you’re billing the correct payer, you can collect an estimated amount each visit and settle up once claims are paid.

But the last goal -transparency- is the most difficult to achieve.

When you obtain an electronic benefits quote, the mental health benefits could conceivably be:

  • Part of the general medical benefit (parity, after all…)
  • Listed separately as a mental health benefit.
  • Could be considered as the same as any medical “specialist” office visit.
  • Some plans even consider mental health as paying the same as primary care.

How are we to know?

Legally speaking, the benefits are what’s contained in the client’s Certificate of Coverage. Period. Doesn’t matter what the customer service rep said. Doesn’t matter what you printed out from Availity. The problem is, short of a power of attorney, clinicians aren’t legally allowed to access Certificates of Coverage.

You can’t seriously be saying I need to get a power of attorney?

Of course not.

What I am saying is, that instead of looking at the needs of the client as opposite from your own and incompatible with your own, why not work together with the client on the issue of benefits?

And now I come to boundaries. Both the client and the clinician have responsibilities.

  • The client’s responsibility is to access the information that the insurance payer makes available to them, that the professional isn’t allowed to see.
  • The provider’s responsibility is to use their greater experience of mental health benefits to read what the client accesses and try to interpret it in a way that provides at least some transparency for the client as to how much they will owe.

To this end, I’ve developed a brand-new Notice of Benefit Verification form in an attempt to summarize and document a collaborative benefit verification process in a way that clarifies expectations for all parties involved. And because the form is then completed on paper or electronically, it can be referred back to as needed.

Hopefully, the collaborative method results in fewer misunderstandings with clients and fewer tense conversations about paying for therapy. The end goal being to decrease benefit verification headaches for clinicians who participate with insurance!

Empowerment

I do believe this approach is empowering – to both clinicians and clients.

The clinician benefits are obvious:

  • Fewer benefit verification headaches.
  • Less time spent on hold trying to get accurate benefits (and failing because the customer service person can only read you the same information you’d get on the portal).
  • Less time on hold means more time for completing notes, collateral contacts with other professionals involved in your clients’ care, marketing, billing, clinical supervision or peer support, continuing education…or time for family and self-care.
  • Less risk of burnout.
  • All without jeopardizing your reimbursement!

But it could be empowering to the client, too.

  • The client can develop the confidence to challenge the insurer if they think a mistake was made – with the therapist’s support. Not taking over for the client or doing for them what they can do for themselves.
  • Enables the client to invest in / take ownership of their treatment.
  • Models healthy boundaries. This positive experience can, with therapy, be transferred to other situations in the client’s life.
  • Above all, the therapeutic alliance is strengthened rather than triangulated.

One caution: some provider contracts and / or manuals state explicitly that deductible or coinsurance (percentage) amounts shouldn’t be collected until after the claim is processed. In the insurer’s view, the fault is in the timing of collections. You are supposed to make good faith efforts to collect patient responsibility amounts – but by forbidding time of service collections, they’re tying your hands. And in an era of 4-figure deductibles, is this even reasonable? It risks you losing significant income.

Insurers impose these prohibitions because they want to shield their members from providers who collect more than they should, perhaps unintentionally, but then don’t refund. But is such a prohibition legal?

I did a quick AI review of these questions: Is there any state that forbids collection at time of service for private insurance?

The answer: No. In fact, Minnesota was highlighted as a state where the laws forbid health insurers from prohibiting time of service collections.

Does the ACA forbid time of service collections?

Again, AI’s answer was NO. The caution was only that the ACA requires transparency and accuracy in healthcare cost-sharing. Well, now you have the basis of a form to ensure that you’re following ACA transparency requirements.

The other cautions I was given were things I already knew, and didn’t really apply. For example, no balance billing. Or that failure to refund is against the law.

Which makes me wonder … how legal is this prohibition in manuals and contracts against time of service collections? That’s a question for a lawyer. Or maybe the IRS and/or the US Dept of Labor, if they interpret this to mean that a clinician is, in fact, an employee of the insurer, and not a contractor.

That said…if you have any doubts about a specific situation or payer, be sure to do your due diligence. A blog can’t possibly address every conceivable situation out there. And just when I think I’ve seen them all…!

I’m always available for individual or group consultations. And later in January 2025, watch for information about subscribing to The Rescue BillerTM – a comprehensive collection of all these arcane rules. All in one convenient location, and based on extensive research.

Susan Frager | PsychBilling Coach

Enter your information to receive the latest news, promos, and discounts from PsychBilling Coach!

Additional Posts: