May 31, 2022
Carlene MacMillan, MD
Regardless of whether or not you accept insurance in your mental health practice, it is impossible to avoid addressing it with patients because they will have questions about their coverage and what it means when they seek mental health treatment. It can seem overwhelming at first but here are 5 tips to keep in mind when it comes to working with insurance:
If you are out-of-network with a patient’s insurance and they have out-of-network benefits (typically, PPO plans but not HMO or EPO plans), utilize Osmind’s superbill generation capabilities to provide them with the documentation needed to maximize any eligible reimbursement. Osmind can even submit these superbills for patients on their behalf; they just need to submit it through their app. Insurance companies will send patients EOBs directly via snail mail. Though the reimbursement is finicky with racemic ketamine, we have seen some high reimbursement rates, so it may be worth trying. If you don’t remember how to set this up, please contact Osmind’s support team, and check out Osmind’s Ketamine Billing Coding Guidebook.
Consider seeking out single case agreements with payers to cover specific courses of treatment for a specific patient. Usually this is initiated by the patient contacting their insurance company and asking if they would consider an out-of-network exemption due to not having qualified practitioners within their network for a specialized service. Steps vary from there but this can be a way to explore taking insurance without getting in over one’s head. Keep in mind with these agreements, rates are often negotiable and there may be more flexibility than with a standard payer contract for an in-network provider.
For individuals with no out-of-network benefits and no possibility to secure a reasonable single case agreement (such as if an off-label service like ketamine infusions for depression is simply uncovered by a payer), develop best practices around Financial Hardship agreements or Sliding Scales for certain types of services that involve the consistent collection of financial information similar to that sought out in educational financial aid applications. Please be aware that “sliding scales” are meant to be applied for anyone who clinically qualifies for a given service whereas there is more ability to limit the number of Financial Hardship slots a practice or clinician can offer based on business considerations so these terms should not be used interchangeably.
Regardless of whether or not you take insurance, sloppy or inconsistent practices around granting fee reductions can cause major medicolegal liability.If you are in-network with an insurance company, keep in mind there are specific contractual prohibitions around things like waiving co-pays or deductibles. When in doubt, check with a local healthcare attorney. Oftentimes, local medical societies offer complimentary consultations with these attorneys for their members for questions around these topics so could be a good starting point.
January 1 is often the time health insurance plans reset although this can vary and is up to each employer. Even if you are totally out-of-network, provide anticipatory guidance to your patients that they should be aware of possibilities like out-of-network deductibles resetting, changing insurance coverage policies around prescription drug coverage for long-standing medications, and changes to out-of-pocket maximums. In addition, it is increasingly common for mental health clinicians to be in-network with only a handful of insurance carriers as they explore if taking insurance makes sense. Some patients may assume that like a primary care office, your practice is in-network with many more plans than they are and not realize a change in their insurance company in January or due to a job change could mean services at your practice are no longer covered. Be proactive in asking about any upcoming insurance changes before visits and not finding out the hard way after the fact.
Dr. Carlene MacMillan is Vice President of Clinical Innovation at Osmind. She is the founder of Brooklyn Minds Psychiatry, a multidisciplinary team-based, multi-site practice in New York City. Her practice was one of the first to offer deep TMS for OCD and esketamine for severe depression and suicidal thinking.
Dr. MacMillan is an expert in mental health communities, with a large following on platforms including Clubhouse (@psychiatrist), where she champions awareness of evidence-based and innovative approaches in psychiatry. She is a member of the Ketamine Taskforce for Access to Safe Care and Insurance Coverage, and the Clinical TMS Society Insurance Committee. She is the Co-Chair of the American Academy of Child and Adolescent Psychiatry Consumer Issues Committee.
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