3 ms·

Also a practicing clinician and this is such a terrible problem that goes well beyond what you’ve described Someone comes in and has insurance “x”. “Am I in ne

Also a practicing clinician and this is such a terrible problem that goes well beyond what you’ve described Someone comes in and has insurance “x”. “Am I in network?” I don’t know. Probably. I take those plans most of the time. I check Navinet, or provider express, or one of the many other insurance benefits verification websites because the various insurers can’t agree on one centralized platform for this. It says you’re good and I’m in network, great! Or you checked the provider directory online and I’m listed. Most of the time we’re okay. Sometimes this is out of date though (the “computer issues” you mentioned). The only way to truly be sure is to call the insurance company and have them check their systems which I simply don’t have time to do, sorry, or submit billing. This is why I and basically every healthcare practitioner have the policy that you are ultimately responsible to verify your benefits. So we meet and it’s fine and I collect your copay. Then I submit billing. Then we meet again weekly. Then the insurance takes four fucking months to process your intake session only to come back and say “hey wait, this actually isn’t covered because it’s technically out of network so neither are the 15 sessions that happened afterward”. Now you suddenly owe me 2-3 grand out of pocket and I either have to collect that, probably worsening your mental health by adding a signicant sudden expense, or write it off and basically say goodbye to any renumeration for the 16 hours of work I did. I will ask you to appeal of course. This isn’t even a “rare exception” situation. It comes up like once a month and I run an independent solo outpatient practice. Low volume. It’s a fucking nightmare. I get why your wife went to out of pocket. I don’t blame her. but then it’s the conflict of making services less accessible. My patients often have no clue how to submit for reimbursement and insurers seem to purposely make this a difficult process. It really just sucks. I tend to work with lower income populations that really rely on insurance coverage so it’s not an option to go cash only for me but I definitely understand those who do. the system we have is deeply flawed, maybe irreparably. The only setting that alleviated this was larger settings. Major healthcare networks/hospitals, large agencies, etc. it still came up but less often and when it did there was an army of billing staff to appeal. But the downside is that imo care was inherently compromised in these settings due to demands placed on staff. There were benefits of having teams, training resources, increased supervision, etc. but all of these were outweighed by significant overhead costs and productivity demands. For perspective moving to private work allowed me to earn 35% more while working 20% less within the first year. I’m not struggling to make ends meet and I’m not constantly flirting with burnout anymore. So imo those institutions aren’t the solution unless they can make real systemic changes

FireBeyond 3y ago
> Then the insurance takes four fucking months to process your intake session only to come back and say “hey wait, this actually isn’t covered because it’s technically out of network so neither are the 15 sessions that happened afterward”. Now you suddenly owe me 2-3 grand out of pocket and I either have to collect that, probably worsening your mental health by adding a signicant sudden expense, or write it off and basically say goodbye to any renumeration for the 16 hours of work I did. I will ask you to appeal of course. Not a clinician but did (previously) work in software developing claims benefit management software. One of the parts of the recent Surprise Billing reforms was that if a patient "could reasonably believe" that they were in network (and in particular, the prominent example of note being the insurer's website or a provider they use lists the provider as being in-network, because they ostensibly have control or input thereinto), then the insurer was obligated to remunerate the claim as being in-network. i.e. if insurance's directory says "sure, provider X is in-network", they don't get to turn around after you use their service and say "You know what, they're not, so this is uncovered/out-of-network".
- hellotheretoday 3y ago
  My billing subcontractor has mentioned this as well but in practice it hasn’t worked extremely for us. Sometimes we resubmit and it gets paid, sometimes not. That’s where I often have to get the patient to directly appeal to their insurer. But I’m not sure if the subcontractor is necessarily following necessary procedures. That’s a whole different issue though; I’ve had to change subcontractors twice in my career because after auditing I found they were dropping the ball on stuff like this and just billing clients when there was a path to insurance reimbursement that could be pursued. To insurance companies credit this is an issue at least a part of the time; billing departments and subcontractors that flake on their own work. Far less common but a non zero part of the issue. Thankfully as things transfer to software solutions this becomes less of an issue; I’ve moved a portion of my billing to a software based billing solution rather than a human one and while it still has issues it has less. Sucks for job creation but better for my patients I guess Now I might do another deep billing audit
jwestbury 3y ago
Even beyond insurance, the system is fucked. My wife finished her master's program and started working under supervision. But, of course, the only places which offer supervision are (generally) community mental health centers. So my wife was fresh out of school, with a client load of 55 people, getting paid $20/hr -- and those 55 people were generally the people with the least resources and support, thus some of the most challenging non-inpatient clients you'll find in mental health. Beyond that, she learned that these community mental health centers, despite being nonprofits, are still aiming to constantly reduce costs; in her first six months, she saw many support structures for both clients and clinicians cut. This included laying off most of the case management staff, expecting the counselors to pick up the slack. She rarely even had time to keep her (legally-required) notes. She lasted less than a year before quitting. She's not sure she'll ever go back. Counselors are being squeezed from both sides here: They either burn out early, or the insurance companies fuck them over in perpetuity.

FireBeyond 3y ago

> Then the insurance takes four fucking months to process your intake session only to come back and say “hey wait, this actually isn’t covered because it’s technically out of network so neither are the 15 sessions that happened afterward”. Now you suddenly owe me 2-3 grand out of pocket and I either have to collect that, probably worsening your mental health by adding a signicant sudden expense, or write it off and basically say goodbye to any renumeration for the 16 hours of work I did. I will ask you to appeal of course. Not a clinician but did (previously) work in software developing claims benefit management software. One of the parts of the recent Surprise Billing reforms was that if a patient "could reasonably believe" that they were in network (and in particular, the prominent example of note being the insurer's website or a provider they use lists the provider as being in-network, because they ostensibly have control or input thereinto), then the insurer was obligated to remunerate the claim as being in-network. i.e. if insurance's directory says "sure, provider X is in-network", they don't get to turn around after you use their service and say "You know what, they're not, so this is uncovered/out-of-network".

hellotheretoday 3y ago
My billing subcontractor has mentioned this as well but in practice it hasn’t worked extremely for us. Sometimes we resubmit and it gets paid, sometimes not. That’s where I often have to get the patient to directly appeal to their insurer. But I’m not sure if the subcontractor is necessarily following necessary procedures. That’s a whole different issue though; I’ve had to change subcontractors twice in my career because after auditing I found they were dropping the ball on stuff like this and just billing clients when there was a path to insurance reimbursement that could be pursued. To insurance companies credit this is an issue at least a part of the time; billing departments and subcontractors that flake on their own work. Far less common but a non zero part of the issue. Thankfully as things transfer to software solutions this becomes less of an issue; I’ve moved a portion of my billing to a software based billing solution rather than a human one and while it still has issues it has less. Sucks for job creation but better for my patients I guess Now I might do another deep billing audit

jwestbury 3y ago

Even beyond insurance, the system is fucked. My wife finished her master's program and started working under supervision. But, of course, the only places which offer supervision are (generally) community mental health centers. So my wife was fresh out of school, with a client load of 55 people, getting paid $20/hr -- and those 55 people were generally the people with the least resources and support, thus some of the most challenging non-inpatient clients you'll find in mental health. Beyond that, she learned that these community mental health centers, despite being nonprofits, are still aiming to constantly reduce costs; in her first six months, she saw many support structures for both clients and clinicians cut. This included laying off most of the case management staff, expecting the counselors to pick up the slack. She rarely even had time to keep her (legally-required) notes. She lasted less than a year before quitting. She's not sure she'll ever go back. Counselors are being squeezed from both sides here: They either burn out early, or the insurance companies fuck them over in perpetuity.