DATE: October 04, 2025 at 05:09PM
SOURCE: PsychBilling Coach In the News by Susan Frager
-------------------------------------------------

TITLE: Medicare demands in-person! What happens now with telehealth?

URL: https://psychbillingcoach.com/news/what-happens-now-telehealth/

After 5 1/2 years, the COVID-era Medicare telehealth waivers expired October 1st when the government shut down. What happens now, if you’re seeing Medicare clients via telehealth?

I realize that anxiety is high and misinformation might be floating around online in professional forums. This stuff isn’t easy to sort through which is why it’s taken me a few extra days! That and, well, Life…

In response, I’m summarizing the most up-to-date information publicly available. Hopefully, reading the facts in plain English, and recommendations for actions with your clients, will be helpful. Everyone will need to decide what happens now in their practice. 

What happens now with my clients?

The first thing to know about telehealth and Medicare is that unlike for medical issues, Medicare permanently covers telehealth for mental health treatment. If you click the link, scroll down to the section that’s specific to behavioral health.

• There are no geographic restrictions for mental health.
•
• Audio-only coverage is permanent for mental health.
•

This isn’t true for medical services. The type of practice/facility matters, too. If you practice in a federally-qualified health center (FQHC) or rural health center (RHC), their rules are different. So be sure the material you’re reading pertains to you!

For mental health private practice, the only thing new as of October 1st is that in-person visits are now required prior to telehealth services. And you / your Medicare clients are going to have some uncertainty for a while if you’re telehealth-only.

Will Congress “temporarily” waive in-person requirements again when they fund the government? Or maybe they’ll pass one of the pending bills which propose removing in-person requirements? Who knows! Instead, let’s focus on what happens now. Speculating about politicians is never very helpful!

Until further notice, the rules are:

• At least 1 in-person visit is required prior to any telehealth visits. The qualifying in-person session must be within 6 months of commencing telehealth.
•
• Thereafter, at least 1 in-person visit every 365 days is required.
•

The questions clinicians are asking:

• Are there any exceptions?
•
• What if I have no way to see a client in person?
•
• What about Medicare Advantage?
•
• If I’ve been seeing a client via telehealth all along, can I keep seeing them telehealth after October 1 and be paid? Or does my first October visit need to be in person?
•
• What should I do to ensure I get paid for telehealth visits going forward?
•

Are there any exceptions?

Yes, but ONLY about the in-person follow-up visit every 12 months. There is no exception whatever for new clients. New clients must be seen in person. (Unless the rules are changed again.)

Medicare describes the exceptions for in-person follow-ups with a lot of very non-specific words:

If the patient and practitioner consider the risks and burdens of an in-person service and agree that … these outweigh the benefits … and the practitioner documents the basis for that decision in the patient’s medical record, then the in-person visit requirement is not applicable for that 12-month period. …

…situations in which the risks and burdens associated with an in-person service may outweigh the benefit could include … instances when an in-person service is likely to cause disruption in service delivery or has the potential to worsen the patient’s condition(s). … Other examples … may include the clinician’s professional judgement that the patient is clinically stable and/or that an in-person visit has the risk of worsening the patient’s condition, creating undue hardship on self or family, or if it is determined that the patient is at risk for disengagement with care that has been effective…

Say what?

It would REALLY be nice if Medicare would say “we’ll cover A, B, and C, but not D, E, or F.” Unfortunately, that’s not how Medicare frames things.

Think of it this way: they’re actually TRUSTING clinicians to use clinical decision-making. What a concept!

Based on the above, if you documented in the client’s record things like these, you’d probably be okay in terms of Medicare agreeing that in-person follow-ups aren’t required:

• In-person appointments are impossible or inadvisable due to a medical condition and/or disability. List the specific issues. How or why does/do the condition(s) risk harm if visits are in-person? Medicare will be especially likely to agree with you if your records show that telehealth treatment to date has been effective.

• I’ve been asked if it can be the clinician’s issues, rather than the client’s, that can be the basis of an ongoing treatment telehealth exception. The statute linked above doesn’t specify that the issue be the client’s. A lawyer specializing in the Americans with Disabilities Act might be a good resource for this question.
•
•
• Client has transportation difficulties. Or maybe they live in a rural area. Maybe your office is a long commute. If they were told they had to be seen in person, how would this impact ongoing treatment? Be clear: exactly why isn’t it possible for the client to have only 1 in-person visit in 365 days?
•

Always be sure to emphasize safety in your documentation: is the client safely managed via telehealth? Document there are no risks present (for example: suicidality) that would necessitate an in-person contact.

This is by no means an exhaustive or definitive list. Auditors will agree (or not) based on the thoroughness of your documentation. It’s up to you to make a convincing case in the client’s clinical record for an in-person exception.

What if I have no way to see a client in person?

Medicare is going to ask why not. If the reason is that you’ve expanded your practice to geographic regions where clients live too far to travel to your office even once per year, then that’s probably not going to be grounds for Medicare agreeing to waive the ongoing in-person requirement.

But if the client can travel to where you’re located for an in-person visit just once per year, then the criteria would be met. So, for instance, let’s say you started services with a client who has since moved out of your area, but comes back occasionally to visit friends/family. Just arrange with the client to have an in-person session with them whenever they’re next in town. Problem solved.

(Note that the above is true whether the client lives in or out of the state you practice in. For this discussion, I’m assuming you’re appropriately licensed wherever you need to be).

Clinicians who’ve given up their physical offices are going to have to make a choice about what happens now with their practice. There are plenty of creative options.

• Arrange with a colleague to borrow their office on an as-needed basis.
•
• Set up an account at a co-working space* where you can rent a physical office by the day or hour, as needed.
•
• Medicare covers in-home visits (POS 12). There are definitely pros and cons to going to client homes to conduct sessions, but it’s an option.
•
• Find a medical practice you can arrange to rent from. Bonus: it might be a source of referrals!
•
• Join/form a local therapist networking/consultation group and rent an office together. The group would have to have someone willing to organize the logistics and take charge, but it could work. Maybe in recognition of the time it takes to do the paperwork, communicate with the landlord, pay the rent, manage the schedule / ensure everyone pays their share, that person could get their office hours at no charge.
•

IMPORTANT! If you add a physical office, even “as-needed,” or if you want to see clients in their homes, you’ll need to update your Medicare enrollment. Medicare typically won’t pay for a service location reported on a claim if that location hasn’t been added to your provider enrollment profile.

*If you’re going to use a co-working space, there are additional things you need to know contact me for a consultation prior to enrolling, to save yourself some headaches!

Some clinicians tell me they’re going do nothing and hope when the government is funded, the waiver will resume. Or that one of the pending telehealth bills will pass. Or that the 2026 Physician Fee Schedule, which should be released in about a month, will settle the in-person question.

This wouldn’t be my recommendation. However, there are many clinicians who are frustrated with low Medicare reimbursement, complex enrollment processes, and unfathomable rules. The resumption of in-person visit requirements might be the last straw for some. Regrettably, there will be clinicians who will respond by opting out of Medicare. Do the politicians understand this? That’s up to us.

What happens now with Medicare Advantage? Will they stop covering telehealth completely?

Not if they want to comply with existing federal law. A refusal to cover telehealth for mental health services would place an Advantage payer in violation of 42 CFR § 422.101, which states that Advantage plans must cover all services covered by Original Medicare. Since Original Medicare, Part B, covers telehealth for mental health, Advantage plans must as well.

With regard to the in-person visit requirement, it’s more complicated. Medicare Advantage plans must always cover anything Original Medicare does, but they also have the option to cover things that Original Medicare doesn’t. This is why so many people choose Advantage plans, even though there are restrictive networks and prior authorization. In the past, Advantage plans have covered dental, vision, hearing aids, over the counter medications, transportation to doctor appointments, gym memberships, and so forth.

What happens now with Medicare Advantage is that in-person visit rules are going to be at the discretion of each individual Advantage payer. If you don’t want to have to sit on endless hold trying to determine what every plan is going to require, my suggestion is to use Original Medicare rules with Advantage clients.

Can I continue to see existing clients via telehealth? Or do I need an in-person visit right away?

No one is 100% certain!

The APA’s opinion is that you can continue via telehealth with existing clients without first doing an in-person visit after October 1st. But even with existing clients, you’re still obligated to do the yearly in-person session sometime before September 30, 2026 unless the rules change again! However, the Center for Connected Health Policy seemed to think an in-person visit immediately after October 1 would be required.

At this time, my best guess is that the APA is correct as to what happens now. Why? Well, for one thing, they specialize in mental health whereas the Center for Connected Health Policy has to address all medical specialties. The APA cited the relevant passage from the 2023 Physician Fee Schedule Final Rule:

From page 69464: “However, we clarify that we do not believe this requirement applies to beneficiaries who began receiving mental health telehealth services in their homes during the PHE.”

While the PHE (the COVID public health emergency) has long since expired, the waivers to statutory telehealth policy kept getting extended. It’s those waivers which ended at midnight on October 1st.

What should I do to ensure I get paid for telehealth visits?

If in-person isn’t an option (for whatever reason), do two things at your first October telehealth visit:

• Have the client sign an Advanced Beneficiary Notification form this form allows clients to pay cash to an enrolled Medicare provider for non-covered services, either at time of service or if Medicare denies the claim. Be sure to use the appropriate modifier(s) if submitting claims!
•
• Document clearly and specifically why an in-person session wasn’t conducted.
•

We’re going to have a bit of a wait before we have a definitive answer to the question “what happens now.” Fortunately, my experience with Medicare’s auditors is that they usually choose records from periods when Medicare policy isn’t in flux which isn’t October 2025!

With regard to in-person visits, all anyone can do is attempt to follow the rules to the best of your ability, document clearly when and why you can’t, and make plans for the future given your individual situation. If you want to explore your options in a consultation, many of your colleagues have found it helpful.

URL: https://psychbillingcoach.com/news/what-happens-now-telehealth/

Articles can be found by scrolling down the page at https://psychbillingcoach.com/news/ under the title "In the News".

-------------------------------------------------

This robot is unaffiliated with PsychBilling Coach.

Private, vetted email list for mental health professionals: https://www.clinicians-exchange.org

Unofficial Psychology Today Xitter to toot feed at Psych Today Unofficial Bot @PTUnofficialBot

Psychology news and research articles at Psychology News Robot @PTUnofficialBot

NYU Information for Practice puts out 400-500 good quality health-related research posts per week but its too much for many people, so that bot is limited to just subscribers. You can read it or subscribe at @PsychResearchBot

Since 1991 The National Psychologist has focused on keeping practicing psychologists current with news, information and items of interest. Check them out for more free articles, resources, and subscription information: https://www.nationalpsychologist.com

EMAIL DAILY DIGEST OF RSS FEEDS -- SUBSCRIBE: http://subscribe-article-digests.clinicians-exchange.org

READ ONLINE: http://read-the-rss-mega-archive.clinicians-exchange.org

It's primitive... but it works... mostly...

-------------------------------------------------

#psychology #counseling #socialwork #psychotherapy @psychotherapist @psychotherapists @psychology @socialpsych @socialwork @psychiatry #mentalhealth #psychiatry #healthcare #psychotherapist #doctors #psychotherapist #hospital #HIPAA #privacy #BAA #patientrecords #telehealth #medicalbilling #SusanFrager

DATE: September 22, 2025 at 05:32AM
SOURCE: PsychBilling Coach by Susan Frager
-------------------------------------------------

TITLE: Death by 1,000 cuts: EDI Enrollment

URL: https://psychbillingcoach.com/edi-enrollment-1000-cuts/

Of all the 1,000 cuts I’ll be featuring in this blog series, Electronic Data Interchange / EDI enrollment is the least publicly discussed and the most poorly understood. Because it seems so onerous and difficult to struggle through, and can be so incomprehensible, many clinicians avoid it. Instead, they stay with time-consuming, manual processes. Or else skip important revenue cycle management functions altogether, risking significant financial losses.

What’s EDI enrollment?

It’s the ironic act of requiring paperwork to obtain permission to engage in electronic transactions with insurance payers. Even though “paperwork” is now usually one or more web-based registration forms, it can be inefficient and the cause of costly delays for which clinicians pay the price, not only in terms of lost revenue, but also lost time. In other words, one of the “1,000 cuts” that contributes to burnout.

EDI enrollment isn’t usually required anymore to submit claims, except for government payers. But electronic remittance advice (ERA), which is the way to receive Explanation of Benefits (EOB) forms electronically, almost always requires enrollment.

This is the general process of EDI enrollment:

Step 1. You decide to enroll to receive ERA from a payer.

Step 2. Complete your EHR and/or clearinghouse’s enrollment request.

Step 3. Paperwork from your clearinghouse, the payer, and/or an intermediary downloads, requiring either completion on a web portal or a pdf (or both). Sometimes the pdfs require a live signature, so you have to print, sign, scan back in.

What’s an intermediary?

Not all systems have direct connections to all payers. So they form agreements with another entity who transmits directly to/from the payer. That entity (usually another clearinghouse) is the intermediary, sometimes called a trading partner.

On February 21, 2024, the world found out just how critical intermediaries are. The largest one, Change Healthcare, was breached in a cyberattack that caused massive devastation to healthcare commerce.

Step 4. (yes, there’s more…!) You upload/submit your paperwork to the payer and/or intermediary.

Step 5. You notify your clearinghouse that your enrollment was submitted. This step is critical; forget it, and there will be no follow-up on your enrollment.

Step 6. Hurry up and wait. If you’re lucky, ERA enrollment takes no more than a week. But I’ve also known it to take more than 6 months.

EDI Enrollment is awful when: Congressional intervention is required!

True story! A psychologist moved to a new EHR, thus requiring all new EDI enrollments. About two months previously, she’d changed her address, updated Medicare and received a letter confirming the change. However, when the psychologist filed her new EDI enrollment paperwork, the Medicare contractor rejected it. Why? “Incorrect address.”

After an hour on the phone during which I was transferred 4 times and must have said 50 times, “our address was changed, the reference number on the approval letter is 12345678,” the EDI department refused to help, insisting I talk to Provider Enrollment. Because after all, Provider Enrollment handles address changes. Provider Enrollment said “we changed the address, you have the confirmation letter, EDI handles EDI enrollment, we don’t get involved with that and they should have the provider’s address, we did our job.”

I was a hot potato no one wanted to touch. God forbid they should talk to each other, I mean, they only work for the same company…

Finally, a Provider Enrollment supervisor said he would notify EDI. Following up two weeks later was another hour on the phone where I impersonated a tennis ball. And it was the same story: EDI stubbornly refused to approve enrollment despite me offering to send them a copy of the address update confirmation. Absolutely not! It had to come from Provider Enrollment and them alone. But they were unwilling to contact Enrollment.

After 4 months of trying various strategies, during which time the psychologist was unable to submit claims to Medicare (and be paid), I suggested she file a Congressional complaint. Frustrated beyond belief, she contacted her Representative’s office.

Without admitting any fault, the EDI department suddenly, mysteriously, managed to “find” the psychologist’s new address and accepted her EDI enrollment. In June, 2025, after 6 months, she finally began receiving payments from Medicare.

EDI Enrollment is awful when: Change Healthcare is involved!

In case you’re thinking the Medicare example is just government bureaucracy and that it’s not so bad in the commercial world, try enrolling for ERA with Aetna. Their ERA enrollment process runs through Change Healthcare. If you begin receiving ERA in under 4 months, that’s an impressive speed.

Pre-cyberattack, Change denied a psychologist I was enrolling on the grounds that his voided check was a “mismatch.” His voided check showed First Name Last Name PH D but he filled out the online form as First Name Last Name PhD.

You can’t make this stuff up!

Payers take responsibility? Nah…

Post-Change cyberattack, many clinicians were required to re-do EDI enrollment for ERA with other intermediaries. But there were payers who never took the trouble to find new EDI routes. During the long months of the Change outage, did those payers turn back time to 2001 and mail paper EOBs?

Some did. But others said: “We’re giving you the means to look up your remittance data on Availity (or some other portal).” If pressed, they admitted sure, one-by-one lookup followed by manual payment posting isn’t efficient for practices.

But so what? Did anything Change? (pun intended) No, of course not. And why not? Because making life easier for healthcare professionals would cost them part of their profits. GASP!

Even without extreme SNAFUs, it’s an exhausting, confusing maze.

EDI enrollment forms can be multiple pages. Take a look at this one from ECHO.

Even shorter and “easier” enrollments, such as Humana’s ERA through Availity, feature wickedly complex instructions. Why is all this necessary?

It wasn’t always like this. Fifteen years ago, ERA was in common use, but none of these complex EDI enrollment gyrations were required.

So why has it become more difficult?

Payers began to require financial transaction (EFT) enrollment be paired with EDI remittance enrollment, opening the doors for additional profit-making schemes. I’ll explore this in the next “1,000 cuts” blog.

There’s a darker motivation here. These complex processes keep clinicians/billers busy chasing our tails hunting down basic financial and remittance data in order to balance our books and invoice clients. The result is a loss of time and/or energy to challenge denials and underpayments.

A second-order consequence is that clinicians may stay with EHR/practice management systems that don’t meet their needs. Because changing to something that would work better means EDI re-enrollment for all payers, with significant revenue delays and a frustrating transition.

When a practice management software platform doesn’t work effectively, who profits? Oh yeah…insurers. They don’t have to pay claims.

And then there’s Medicare’s eligibility enrollment…

Their EDI enrollment paperwork is written in gobbledygook extremely difficult to understand and follow the directions. I’ve given many consultations dedicated solely to guiding clinicians through Noridian’s EDISS enrollment system. Of course it’s nice to have job security, but…really, can someone please explain why EDI enrollment needs to be so convoluted that you have to hire someone to help you? Is that really in the best interests of the efficiency of the healthcare ecosystem?

This summer, Medicare introduced even more hurdles. In order to get automated eligibility inquiries through your clearinghouse, everyone now has to attest annually to the HIPAA Eligibility Transaction System (HETS) Rules of Behavior. Clinicians in First Coast, Novitas, and Noridian jurisdictions are already subject to the attestation requirement. Palmetto and CGS go live this month, with WPS debuting in December. If you don’t do it, automated eligibility inquiry privileges are cancelled. Your only way of obtaining this information will be manual direct data entry on the Medicare contractor’s portal. With a complex enrollment process!

Keeping your sanity

Aside from saying the Serenity Prayer repeatedly, what can you do?

I have a few suggestions:

• Concentrate your efforts on only those payers you interact with most often.
•

• Enrolling for direct deposit (EFT) may cancel paper remittances from commercial payers. If you’re not ready to enroll for ERA, stay away from direct deposit, if you have that option.
•

• Significant Medicare volume makes things worse. Why? Because there are so many Medicare supplement payers to enroll with! And a lot of them use intermediaries who charge fees (more on that in the next “1,000 cuts” blog).

• My advice? Other than AARP and Tricare for Life, stay away from ERA with Medicare supplement plans.
•

•

• Be careful if you do decide to sign up for EFT in order to get ERA. There are intermediaries who charge fees, deducting a percentage of your reimbursement for the “privilege” of receiving what the law says you’re entitled to.
•

• Always read everything prior to signing.
•

• Keep a list of payers who don’t remit by ERA. Once or twice a month, run a report to see which claims are still outstanding, and follow up on any older than 30 days old. If a particular payer is troublesome, consider enrolling for ERA with that one,
•

• Ask your clearinghouse or software vendor for help with the EDI enrollment forms. That’s why you pay them the big bucks!
•

• If you really need ERA from a particular payer and are having a hard time with the enrollment, I can help!
•

I also don’t mind admitting that this is one area in which I like to make some noise! I tell payer, intermediary, and/or clearinghouse representatives why I’m not signing up for ERA if they’re trying to get me to do so and I’ve decided not to proceed. Especially if it involves payment, if I feel that the forms are too difficult, or if the “ERA” turns out to be only a web portal that’s going to involve more labor on my/the clinician’s part and only benefits the payer.

Don’t be afraid to “just say no” to EDI enrollment that, for whatever the reason, is going to make life more rather than less complicated. Mailed paper EOBs certainly have their disadvantages, but on the whole it’s less work than chasing your remittance data through 1,001 web portals. Fighting denials is enough of a challenge.

URL: https://psychbillingcoach.com/edi-enrollment-1000-cuts/

Articles can be found by scrolling down the page at https://psychbillingcoach.com/billing-blog/ under the title "The Billing Blog".

-------------------------------------------------

This robot is unaffiliated with PsychBilling Coach.

Private, vetted email list for mental health professionals: https://www.clinicians-exchange.org

Unofficial Psychology Today Xitter to toot feed at Psych Today Unofficial Bot @PTUnofficialBot

Psychology news and research articles at Psychology News Robot @PTUnofficialBot

NYU Information for Practice puts out 400-500 good quality health-related research posts per week but its too much for many people, so that bot is limited to just subscribers. You can read it or subscribe at @PsychResearchBot

Since 1991 The National Psychologist has focused on keeping practicing psychologists current with news, information and items of interest. Check them out for more free articles, resources, and subscription information: https://www.nationalpsychologist.com

EMAIL DAILY DIGEST OF RSS FEEDS -- SUBSCRIBE: http://subscribe-article-digests.clinicians-exchange.org

READ ONLINE: http://read-the-rss-mega-archive.clinicians-exchange.org

It's primitive... but it works... mostly...

-------------------------------------------------

#psychology #counseling #socialwork #psychotherapy @psychotherapist @psychotherapists @psychology @socialpsych @socialwork @psychiatry #mentalhealth #psychiatry #healthcare #psychotherapist #doctors #psychotherapist #hospital #HIPAA #privacy #BAA #patientrecords #telehealth #medicalbilling #SusanFrager

DATE: September 22, 2025 at 05:32AM
SOURCE: PsychBilling Coach Billing Blog by Susan Frager
-------------------------------------------------

TITLE: Death by 1,000 cuts: EDI Enrollment

URL: https://psychbillingcoach.com/edi-enrollment-1000-cuts/

Of all the 1,000 cuts I’ll be featuring in this blog series, Electronic Data Interchange / EDI enrollment is the least publicly discussed and the most poorly understood. Because it seems so onerous and difficult to struggle through, and can be so incomprehensible, many clinicians avoid it. Instead, they stay with time-consuming, manual processes. Or else skip important revenue cycle management functions altogether, risking significant financial losses.

What’s EDI enrollment?

It’s the ironic act of requiring paperwork to obtain permission to engage in electronic transactions with insurance payers. Even though “paperwork” is now usually one or more web-based registration forms, it can be inefficient and the cause of costly delays for which clinicians pay the price, not only in terms of lost revenue, but also lost time. In other words, one of the “1,000 cuts” that contributes to burnout.

EDI enrollment isn’t usually required anymore to submit claims, except for government payers. But electronic remittance advice (ERA), which is the way to receive Explanation of Benefits (EOB) forms electronically, almost always requires enrollment.

This is the general process of EDI enrollment:

Step 1. You decide to enroll to receive ERA from a payer.

Step 2. Complete your EHR and/or clearinghouse’s enrollment request.

Step 3. Paperwork from your clearinghouse, the payer, and/or an intermediary downloads, requiring either completion on a web portal or a pdf (or both). Sometimes the pdfs require a live signature, so you have to print, sign, scan back in.

What’s an intermediary?

Not all systems have direct connections to all payers. So they form agreements with another entity who transmits directly to/from the payer. That entity (usually another clearinghouse) is the intermediary, sometimes called a trading partner.

On February 21, 2024, the world found out just how critical intermediaries are. The largest one, Change Healthcare, was breached in a cyberattack that caused massive devastation to healthcare commerce.

Step 4. (yes, there’s more…!) You upload/submit your paperwork to the payer and/or intermediary.

Step 5. You notify your clearinghouse that your enrollment was submitted. This step is critical; forget it, and there will be no follow-up on your enrollment.

Step 6. Hurry up and wait. If you’re lucky, ERA enrollment takes no more than a week. But I’ve also known it to take more than 6 months.

EDI Enrollment is awful when: Congressional intervention is required!

True story! A psychologist moved to a new EHR, thus requiring all new EDI enrollments. About two months previously, she’d changed her address, updated Medicare and received a letter confirming the change. However, when the psychologist filed her new EDI enrollment paperwork, the Medicare contractor rejected it. Why? “Incorrect address.”

After an hour on the phone during which I was transferred 4 times and must have said 50 times, “our address was changed, the reference number on the approval letter is 12345678,” the EDI department refused to help, insisting I talk to Provider Enrollment. Because after all, Provider Enrollment handles address changes. Provider Enrollment said “we changed the address, you have the confirmation letter, EDI handles EDI enrollment, we don’t get involved with that and they should have the provider’s address, we did our job.”

I was a hot potato no one wanted to touch. God forbid they should talk to each other, I mean, they only work for the same company…

Finally, a Provider Enrollment supervisor said he would notify EDI. Following up two weeks later was another hour on the phone where I impersonated a tennis ball. And it was the same story: EDI stubbornly refused to approve enrollment despite me offering to send them a copy of the address update confirmation. Absolutely not! It had to come from Provider Enrollment and them alone. But they were unwilling to contact Enrollment.

After 4 months of trying various strategies, during which time the psychologist was unable to submit claims to Medicare (and be paid), I suggested she file a Congressional complaint. Frustrated beyond belief, she contacted her Representative’s office.

Without admitting any fault, the EDI department suddenly, mysteriously, managed to “find” the psychologist’s new address and accepted her EDI enrollment. In June, 2025, after 6 months, she finally began receiving payments from Medicare.

EDI Enrollment is awful when: Change Healthcare is involved!

In case you’re thinking the Medicare example is just government bureaucracy and that it’s not so bad in the commercial world, try enrolling for ERA with Aetna. Their ERA enrollment process runs through Change Healthcare. If you begin receiving ERA in under 4 months, that’s an impressive speed.

Pre-cyberattack, Change denied a psychologist I was enrolling on the grounds that his voided check was a “mismatch.” His voided check showed First Name Last Name PH D but he filled out the online form as First Name Last Name PhD.

You can’t make this stuff up!

Payers take responsibility? Nah…

Post-Change cyberattack, many clinicians were required to re-do EDI enrollment for ERA with other intermediaries. But there were payers who never took the trouble to find new EDI routes. During the long months of the Change outage, did those payers turn back time to 2001 and mail paper EOBs?

Some did. But others said: “We’re giving you the means to look up your remittance data on Availity (or some other portal).” If pressed, they admitted sure, one-by-one lookup followed by manual payment posting isn’t efficient for practices.

But so what? Did anything Change? (pun intended) No, of course not. And why not? Because making life easier for healthcare professionals would cost them part of their profits. GASP!

Even without extreme SNAFUs, it’s an exhausting, confusing maze.

EDI enrollment forms can be multiple pages. Take a look at this one from ECHO.

Even shorter and “easier” enrollments, such as Humana’s ERA through Availity, feature wickedly complex instructions. Why is all this necessary?

It wasn’t always like this. Fifteen years ago, ERA was in common use, but none of these complex EDI enrollment gyrations were required.

So why has it become more difficult?

Payers began to require financial transaction (EFT) enrollment be paired with EDI remittance enrollment, opening the doors for additional profit-making schemes. I’ll explore this in the next “1,000 cuts” blog.

There’s a darker motivation here. These complex processes keep clinicians/billers busy chasing our tails hunting down basic financial and remittance data in order to balance our books and invoice clients. The result is a loss of time and/or energy to challenge denials and underpayments.

A second-order consequence is that clinicians may stay with EHR/practice management systems that don’t meet their needs. Because changing to something that would work better means EDI re-enrollment for all payers, with significant revenue delays and a frustrating transition.

When a practice management software platform doesn’t work effectively, who profits? Oh yeah…insurers. They don’t have to pay claims.

And then there’s Medicare’s eligibility enrollment…

Their EDI enrollment paperwork is written in gobbledygook extremely difficult to understand and follow the directions. I’ve given many consultations dedicated solely to guiding clinicians through Noridian’s EDISS enrollment system. Of course it’s nice to have job security, but…really, can someone please explain why EDI enrollment needs to be so convoluted that you have to hire someone to help you? Is that really in the best interests of the efficiency of the healthcare ecosystem?

This summer, Medicare introduced even more hurdles. In order to get automated eligibility inquiries through your clearinghouse, everyone now has to attest annually to the HIPAA Eligibility Transaction System (HETS) Rules of Behavior. Clinicians in First Coast, Novitas, and Noridian jurisdictions are already subject to the attestation requirement. Palmetto and CGS go live this month, with WPS debuting in December. If you don’t do it, automated eligibility inquiry privileges are cancelled. Your only way of obtaining this information will be manual direct data entry on the Medicare contractor’s portal. With a complex enrollment process!

Keeping your sanity

Aside from saying the Serenity Prayer repeatedly, what can you do?

I have a few suggestions:

• Concentrate your efforts on only those payers you interact with most often.
•

• Enrolling for direct deposit (EFT) may cancel paper remittances from commercial payers. If you’re not ready to enroll for ERA, stay away from direct deposit, if you have that option.
•

• Significant Medicare volume makes things worse. Why? Because there are so many Medicare supplement payers to enroll with! And a lot of them use intermediaries who charge fees (more on that in the next “1,000 cuts” blog).

• My advice? Other than AARP and Tricare for Life, stay away from ERA with Medicare supplement plans.
•

•

• Be careful if you do decide to sign up for EFT in order to get ERA. There are intermediaries who charge fees, deducting a percentage of your reimbursement for the “privilege” of receiving what the law says you’re entitled to.
•

• Always read everything prior to signing.
•

• Keep a list of payers who don’t remit by ERA. Once or twice a month, run a report to see which claims are still outstanding, and follow up on any older than 30 days old. If a particular payer is troublesome, consider enrolling for ERA with that one,
•

• Ask your clearinghouse or software vendor for help with the EDI enrollment forms. That’s why you pay them the big bucks!
•

• If you really need ERA from a particular payer and are having a hard time with the enrollment, I can help!
•

I also don’t mind admitting that this is one area in which I like to make some noise! I tell payer, intermediary, and/or clearinghouse representatives why I’m not signing up for ERA if they’re trying to get me to do so and I’ve decided not to proceed. Especially if it involves payment, if I feel that the forms are too difficult, or if the “ERA” turns out to be only a web portal that’s going to involve more labor on my/the clinician’s part and only benefits the payer.

Don’t be afraid to “just say no” to EDI enrollment that, for whatever the reason, is going to make life more rather than less complicated. Mailed paper EOBs certainly have their disadvantages, but on the whole it’s less work than chasing your remittance data through 1,001 web portals. Fighting denials is enough of a challenge.

URL: https://psychbillingcoach.com/edi-enrollment-1000-cuts/

Articles can be found by scrolling down the page at https://psychbillingcoach.com/billing-blog/ under the title "The Billing Blog".

-------------------------------------------------

This robot is unaffiliated with PsychBilling Coach.

Private, vetted email list for mental health professionals: https://www.clinicians-exchange.org

Unofficial Psychology Today Xitter to toot feed at Psych Today Unofficial Bot @PTUnofficialBot

Psychology news and research articles at Psychology News Robot @PTUnofficialBot

NYU Information for Practice puts out 400-500 good quality health-related research posts per week but its too much for many people, so that bot is limited to just subscribers. You can read it or subscribe at @PsychResearchBot

Since 1991 The National Psychologist has focused on keeping practicing psychologists current with news, information and items of interest. Check them out for more free articles, resources, and subscription information: https://www.nationalpsychologist.com

EMAIL DAILY DIGEST OF RSS FEEDS -- SUBSCRIBE: http://subscribe-article-digests.clinicians-exchange.org

READ ONLINE: http://read-the-rss-mega-archive.clinicians-exchange.org

It's primitive... but it works... mostly...

-------------------------------------------------

#psychology #counseling #socialwork #psychotherapy @psychotherapist @psychotherapists @psychology @socialpsych @socialwork @psychiatry #mentalhealth #psychiatry #healthcare #psychotherapist #doctors #psychotherapist #hospital #HIPAA #privacy #BAA #patientrecords #telehealth #medicalbilling #SusanFrager

DATE: August 05, 2025 at 03:12PM
SOURCE: PsychBilling Coach In the News by Susan Frager
-------------------------------------------------

TITLE: Clinician finances threatened amid 2025’s insurance stock plunge

URL: https://psychbillingcoach.com/news/clinician-finances-insurance-stocks/

If it seems clinician finances are more precarious than usual, no, it’s not your imagination. You don’t have an anxiety disorder. The uncertain economy means that discretionary income for self-pay psychotherapy may be disappearing. But if it seems like dealing with insurance is worse than ever, that’s not your imagination either.

Every day, I see audits, pre-payment reviews, and new creative ways being implemented to delay, deny, or claw back payment. Credentialing and contracting seem to be taking longer, with more mistakes being made that take longer to resolve. Payers are quibbling over 90837 use again. There’s talk of reimbursement rate decreases in some locations, with tech platforms such as Alma or Headway not being exempt. If any of this matches your experience, I’m going to explain why.

The major insurers, especially the ones offering government or Marketplace plans, have been disappointing their shareholders. Profits, apparently, aren’t sufficient. (does anyone hear tiny violins playing?)

Make no mistake: the first duty of an insurance company is to the shareholders. Employers who purchase group policies are a distant second. And policyholders? Hah. Not even on the radar. Except as cost liabilities.

On July 29th, United HealthGroup reported 2025 second-quarter earnings results. Despite an increase of $12.8 billion when compared to second quarter 2024, that apparently wasn’t sufficient. UHG’s stocks decreased another 7% following the earnings call, for a total 2025 collapse of more than 44%. A (probably long overdue) Justice Department investigation into United’s Medicare Advantage “upcoding” practices probably isn’t helping things, either.

Other payers have financial “woes” too. Centene, the largest vendor of Medicaid managed care plans, reported a second-quarter loss of $253 million. Molina, Centene’s competitor in the Medicaid managed care and ACA plan market, also cut its 2025 earnings outlook. And Elevance (Anthem/Carelon) reported a 24% loss in profit to date in 2025.

Don’t let the doom and gloom mislead you. These folks are still making plenty of money! But it’s not enough to satisfy Wall Street shareholders, who expect to see hefty year-over-year profits. Which isn’t a model that is either ethical or realistically sustainable in healthcare.

Does stock outlook affect clinician finances?

Yes. Insurers are going to have to do something to increase profits enough to satisfy investors. I don’t think it takes three guesses to determine whose finances will be targeted.

Here’s looking at…us!

Any way an insurer tries to save money will result in systemic changes that negatively impact clinician finances. For instance, layoffs might worsen delays/mistakes in credentialing and contracting fewer employees to process enrollments. Personally, I’ve never subscribed to the belief that “doing more with less” produces positive results. Seems to me that if you invest less, your results will be, well…less. But hey, they’re saving money in payroll costs!

Who cares if a few clinicians are unhappy or if claims are delayed, right? Recently I had two newly-contracted practices with Aetna report that despite their contract effective dates being more than 60 days in the past, new claims are still processing “out of network.” Aetna laid off over 600 employees in 2024 and 2025. It could be a coincidence. If you believe in coincidences.

Yes, eventually, claims can be reprocessed to pay at the in-network level. But that requires clinicians to call, appeal, dispute all of which takes unreimbursed time and effort. And if claims are paid 90 days later, then Aetna gets 90 days’ worth of interest on clinician finances. In theory, state “prompt-pay” legislation requires insurers to pay interest on late claims, but often that doesn’t happen. And even when it does, the amount of interest paid is probably nowhere near what the insurance company took in during the time claims were delayed.

Check out this lovely little paragraph I found hiding in Optum Behavioral Health (United)’s provider manual:

No interest or penalty otherwise required under applicable law will be due on any claim which was initially processed timely and accurately, but which requires reprocessing as a result of the untimely execution of a Participation Agreement or amendment; or the inability to align Optum systems in a commercially reasonable period of time. (page 71, version effective Aug 15, 2024)

WOW. Optum is outright saying they can be as slow as they like with no consequences. How convenient for United’s bottom line. And how damaging to clinician finances.

There are too many examples of payer shenanigans to provide an exhaustive list, but here are a couple more. All are systematically designed to be destructive to clinician finances and the survival of practices. When practices fail or go out of network, clients can’t access affordable, competent care and claims don’t have to be paid.

• Low reimbursements ensure “Ghost Networks“ which can be literally deadly.
•
• No standardization in billing. Multiple ways to bill for telehealth. Does the payer require a taxonomy code? Why did this payer insist on contracting me with my Type 1 NPI when everyone else uses my Type 2? Etc. People make billing mistakes because it’s almost impossible to keep up with the varying expectations. Claims payment is delayed, stress increases, and clinician finances suffer as some therapists decide their mental health is more important than fighting to get that $80 owed by BC/BS for a session from 6 months ago. It adds up. Payers profit.
•
• Unilateral downcoding policies. Cigna announced that effective October 1st, they’re going to reduce 99214 and 99215 claims down to 99213. It will be up to providers to file reconsideration requests with medical records to prove their services met criteria for Levels 4 or 5. Aetna has already been downcoding for a while now. Unilateral downcoding forces a practice to face two awful choices: 1) bill for what you did and fight with documentation on every single claim in order to collect, OR, 2) bill something less, getting reimbursed even less, but without a hassle (presumably). In the non-prescribing psychotherapy world, this is the dynamic that the “you’re billing too many 90837” letters has created for years now.
•
• No provider customer service. We’re told use portals instead of calling. But when there’s a complex problem to be sorted out, there’s no one to talk to who can help. US-based employees with authority to fix the issues are unreachable. Eventually people just give up out of frustration. (I can help with this!)
•
What’s causing these “losses?”

People are utilizing their health insurance benefits more than the bean counters expected. How dare they?

Insurance executives use the term medical loss ratio (MLR) to refer to the percentage of premiums spent on claims payment. The Affordable Care Act dictates a medical loss ratio of at least 85%. Historically, payers have managed to stay close, but for second quarter 2025, these were the MLR numbers reported:

• United: 89.4%
•
• Elevance: 88.9%
•
• Humana: 89.9%
•
• CVS/Aetna: 89.9%
•
• Centene: 93%
•
Isn’t that a good thing for clinician finances? More claims being paid?

Sure, until they find a way to claw money back. Or reduce reimbursement rates to “compensate.” Or they decide to impose pre-payment reviews and/or unilateral downcoding. In the words of many of the CEO’s presenting the “disappointing” 2nd quarter results, “aggressive provider coding” is responsible for a lot of their “losses.”

Or until payers lay off more employees, complicating your ability to get contracted/credentialed, or changes made to your profile. Fewer people to program/update the systems that adjudicate and pay claims. (Yes, claims are mostly processed by AI algorithms).

Or when the “losses,” together with not-so-beautiful new legislation removing people from Medicaid and the likely ending of expanded ACA subsidies conspire to raise 2026 premiums by about 15%. United has already admitted plans to discontinue Medicare Advantage PPO policies in 2026, which will render about 600,000 seniors scrambling for different coverage that will most likely be both more expensive and with skimpier benefits.

The scariest part of all for mental health clinician finances?

Is that in the flurry of earnings reports, four of the five payers quoted specifically mentioned behavioral health as one of the leading areas of increased costs.

That Wall Street beast must be kept fed.

Need help managing the insanity of insurance billing, or fighting to keep money you earned? I’m here to help!

URL: https://psychbillingcoach.com/news/clinician-finances-insurance-stocks/

Articles can be found by scrolling down the page at https://psychbillingcoach.com/news/ under the title "In the News".

-------------------------------------------------

This robot is unaffiliated with PsychBilling Coach.

Private, vetted email list for mental health professionals: https://www.clinicians-exchange.org

Unofficial Psychology Today Xitter to toot feed at Psych Today Unofficial Bot @PTUnofficialBot

Psychology news and research articles at Psychology News Robot @PTUnofficialBot

NYU Information for Practice puts out 400-500 good quality health-related research posts per week but its too much for many people, so that bot is limited to just subscribers. You can read it or subscribe at @PsychResearchBot

Since 1991 The National Psychologist has focused on keeping practicing psychologists current with news, information and items of interest. Check them out for more free articles, resources, and subscription information: https://www.nationalpsychologist.com

EMAIL DAILY DIGEST OF RSS FEEDS -- SUBSCRIBE: http://subscribe-article-digests.clinicians-exchange.org

READ ONLINE: http://read-the-rss-mega-archive.clinicians-exchange.org

It's primitive... but it works... mostly...

-------------------------------------------------

#psychology #counseling #socialwork #psychotherapy @psychotherapist @psychotherapists @psychology @socialpsych @socialwork @psychiatry #mentalhealth #psychiatry #healthcare #psychotherapist #doctors #psychotherapist #hospital #HIPAA #privacy #BAA #patientrecords #telehealth #medicalbilling #SusanFrager

MGSI Florida – Physician & Provider Credentialing and Practice Support

MGSI delivers expert medical billing and comprehensive provider & physician credentialing services tailored for U.S. healthcare providers, billing groups, and hospitals — simplifying your practice management with precision and compliance, based in Florida.

To learn more, visit: https://www.mgsionline.com/phycisian-credentialing.html

#physiciancredentialingservices
#providercredentialingservices
#medicalbilling #medicalbillingservices