Many mental health providers contact us asking for advice about credentialing.

Is it worth it?  Will I get paid less?  Will I see more patients? Does in-network and out-of-network billing change?

This article will attempt to answer the reasons for and against getting credentialed with insurance panels.  If you have other questions, feel free to ask!

Does Credentialing Status Change Billing?

The 80/20 answer is that it does not.  A CMS1500 form is a CMS1500 form.

There can be some differences, however, but they are so rare that they are absolutely not worth worrying about.

These changes usually only come to fruition when you are billing out of network, where you may need to sign a single case agreement and submit claims with an authorization number associated with that case.  Very infrequently you may be required to submit your taxonomy code as well, but again, this is an extremely rare requirement and will almost never apply to big brand insurance companies like BCBS, Aetna, Cigna, UHC/UBH/Optum, Magellean, etc.

So in short, don’t worry about billing when it comes to network status; it’s the same.

What Are The Pros of Becoming In-Network?

Here they are:

1. Automated Marketing
2. Larger Pool of Clients
3. Higher Likelihood of Repeat Sessions with Clients

Having a hard time increasing the number of clients you’re seeing?  By joining an insurance panel, you’ll be automatically added to a database of possible providers to choose from.  Often times clients will search this database to select an in-network provider because it reduces their out of pocket costs.  Being in their database improves your visibility.

Beyond this, medical providers will be more likely to refer clients to you if you both share the same insurance network coverage.  Medical providers are far less likely to suggest out of network providers to patients in an attempt to help them reduce costs.

Iif a client finds you online they will often times be filtering their searches by the insurance companies that you are in-network with, so if they don’t see their insurance brand on your PsychologyToday profile, they will skip you.

By having a variety of contracts with insurance companies, you’ll organically receive more client leads for your private practice.

And, because they are using their in-network benefits, they are going to have reduced patient out of pocket costs.  This means that they will be more likely to see you over and over, since they are only paying a copay instead of their deductible and co-insurance.  (This 100% depends on their coverage.  Even in-network clients may have high out of pocket expenses, deductibles and coinsurance.  Always check eligibility and benefits to find out, or hire us to help!).

Insurance companies almost always structure out of network benefits to be far more expensive than in-network benefits for their clients.  If a client wants to save money, they are far more likely to use an in-network provider.

What Are The Cons of Becoming In-Network?

1. Reduced Per Session Payment

It’s really that simple, believe it or not.  Your per session reimbursement rate might not be as high as if you were to stay out of network.  But the burden of this payment will rest on the client, most likely.  So while you may be paid more, the client will be paying more.

If the client has incredible coverage then they will not need to pay more out of pocket.  This is your golden opportunity, but it is very rare.

What Are The Pros of Staying Out-Of-Network?

1. Potentially higher reimbursement rates

Again, it’s important to note that these increased rates will fall on the client, most likely, so their liklihood to continue to come see you may be reduced.  But many out of network providers do receive higher rates.

What Are The Cons of Staying Out-Of-Network?

1. Increased authorization requirements
2. Client’s will have worse benefits or no out of network benefits (specifically with Medicaid and Medicare, but other brands as well)

Often times authorization will be required for out of network providers to see clients, so this will require an additional phone call and increasing billing complexity slightly.  You may only have three or six sessions approved as well, making it that much more cumbersome to see a patient long term.

Worse case scenario, the patient has no out of network benefits at all.  If you’ve seen them for an intake to gather their insurance information, you won’t be reimbursed for that session.  This can be a big let down and very frustrating.  To combat this, always request their insurance information before seeing the patient so you can do an eligibility and benefits verification call.

Conclusion

We strongly encourage folks to get credentialed if they want a full-time private practice.  As your demand grows you can slowly lower the percentage of insurance to private pay clients you see.  But the benefits of increased visibility, referrals, marketing, and billing simplicity, along with the savings for clients, are all very compelling reasons to get credentialed.

If you need help with any of the billing, hey!  We’re here to help!  Drop us a line.