Insurance Billing Basics: The Complete Guide to Getting Started with Insurance for Private Practice

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In this short tutorial from Jill Shook, CCC-SLP, you can learn the basics of what it takes to start accepting insurance in private practice.

Click to skip to a section:
00:00 Introduction
0:31 Insurance Vocabulary
2:53 Credentialing requirements
4:30 Contract process
6:15 Providing Therapy as a Provider
7:12 Tips for Confirming Benefits
9:52 Submitting Claims
12:28 Getting Paid

1. Basic Vocabulary:
– EMR/EHR : Electronic Medical Record/Electronic Health Record. HIPAA-compliant digital versions of paper charts that include patient information, notes, evaluations, and insurance info.
– Claim: the invoice/bill you submit to an insurance company. It includesinformation like the NPI of the treating clinician, ICD-10 (diagnosis) code/s, CPT (procedure) code/s, and the patient’s insurance info
– Some people use the term superbill, invoice, and claim interchangeably, but that’s not correct. Those are all slightly different documents.
– Clearinghouse: An intermediary between you and the insurance company that checks claims for accuracy and forward the claim to insurance companies through a process called „claims scrubbing”. Having a clearinghouse is required by most insurance companies.
– EOB: Explanation of Benefits. A form that explains why an insurance company accepts or rejects a claim. Sent to the patient and the provider (will look different for each)
– EFT: Electronic Funds Transfer. A direct deposit from insurance, allowing them to pay you without having to mail a paper check.
– ERA: Electronic Remittance Advice. Information from the insurance company about why a claim was or was not accepted. The electronic form of an EOB.
– Superbill: an itemized form that shows what treatment you provided, the diagnosis, your license number and EIN, and the patient’s insurance information.

2. The Credentialing and Contract Process (Becoming A Provider)

1. This is when insurance companies check your licenses and practice information and decide if they will approve you to become a provider
a. Set up a free CAQH Proview account, and have the following information ready:
– Employee Identification Number (EIN)
– National Provider Identifier (NPI)
– State license number
– Business name, if you have formed an LLC or other business structure
– ASHA number if you have one- it is not required by most companies, but gives additional information
– Professional Liability Insurance coverage paperwork
– Taxonomy code (for SLPs, it is 235Z00000X)

2. Once credentialed, check your contract or the provider page for their fee schedule is and if they have any special requirements like:
a. mandating the session length for specific CPT codes (e.g. some companies require that 92507 be 1 hour long, even though that code is not timed).
b. If there is a required clearinghouse to use in addition to an EMR (Availty, Navinet, etc)

3. Providing Therapy as a Provider
a. Before seeing your first client, verify their benefits, either through the number on their membership card or through your EMR.
b. Info you need about the benefits:
– co-payment- a flat fee that is due at certain medical visits, usually $20-50.
– coinsurance : a percentage of the cost of the procedure, which the patient pays, and/or
– deductible: an amount that the patient must meet yearly before insurance will pay. Coinsurance and co-payments may figure into this, depending on the plan.

4. Submitting claims
a. After the session, write up a claim, usually on a CMS 1500 claim form.
b. Simple Practice will auto-populate the form for you from your session notes.
– Date/s of service
– ICD-10 (diagnosis) codes
– CPT (procedure codes) and any modifiers
– Place of service (location code)
– Rendering provider with your NPI
– Billing Facility (this would be your Type 2 NPI)
– The patient’s address, insurance information, and date of birth
c. Submit claim it to the clearinghouse that is required by the insurance company (most can be submitted through SimplePractice)
i. Make sure you submit the claim within the Timely Filing requirements, which can vary by insurance company! Many companies allow 365 days from the date of service, but some only allow 90.

5. Getting Paid
a. In most cases, you will receive your ERA directly to your EMR
b. This can take anywhere from a few days to a few weeks (or, in some cases with Medicare or Medicaid, a month or two).
c. Once the claim is accepted, you will be paid by the insurance company, either through an EFT directly into the account you specify or through a paper check.

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Jill Shook and SimplePractice are providing this information for educational purposes only and it does not substitute for accounting or legal advice.

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