DATE: March 22, 2026 at 02:16PM
SOURCE: PsychBilling Coach In the News by Susan Frager
-------------------------------------------------

TITLE: Data Breach! Why discovering your clearinghouse matters.

URL: https://psychbillingcoach.com/news/discover-your-clearinghouse/

TriZetto is a major electronic data interchange (EDI) clearinghouse. It’s not one of the more well-known ones in mental health billing, but it powers more systems than one might realize. If you’re a Tebra user, your clearinghouse is TriZetto. Other systems that may be using TriZetto include PracticeQ, ICANotes, Pimsy, Valant (if you contracted with them before they began using Waystar exclusively). Typically these systems allow a choice of clearinghouse do you remember what you chose? Was it someone else’s choice?

Any system can have a data breach, and health care systems contain all the information hackers need to steal identities, blackmail individuals, and probably more heinous things than I can even dream up. So I’m certainly not minimizing the effect of this one, which exposed 3.4 million people’s information for 10 months before it was discovered in October 2025. Worse, the owner of TriZetto, Cognizant Technologies, didn’t disclose the data breach to providers until December 2025. Affected patients didn’t learn about it until February 2026.

Why the delay? Unknown. Read more about the data breach here.

Data breaches in systems that we use and have Business Associate Agreements with aren’t under our control but this latest breach emphasizes the need for you to know what’s under the hood of your Electronic Health Record (EHR). 

Many clinicians I consult with don’t know what a clearinghouse is or what it does, let alone which one(s) their system uses. Often, you don’t get to choose your clearinghouse your system has chosen it for you. Some systems integrate with only one clearinghouse (or own the clearinghouse used). Others, such as the systems mentioned above, allow at least a limited choice of external vendors.

Think of the clearinghouse as the engine that drives your practice management system. The software platform upon which your client portal is based, and where you complete clinical documentation, can’t perform the three major insurance EDI transactions without external connectivity to payers: eligibility/benefits, claims, and electronic remittance advice (ERA). That connectivity to payers is typically handled by the clearinghouse, which converts the data you view in an intuitive format, to the HIPAA-mandated language of electronic commerce, ANSI 5010X12. (I know! It sounds intimidating, and if you look at ANSI transmissions, you’d think it gobbledygook). Think about it this way: you may be able to sit in a lovely, comfortable car, but it will go nowhere without an engine.

Not all clearinghouses are able to transmit directly to all payers. Insurance companies have bought up some of the major clearinghouses and have restricted EDI gateways in and out to gain economic control. For example, one of the largest clearinghouses is everyone’s “love-to-hate,” Availity, which is owned by a partnership of about half the Blue payers in the US plus Humana. Anthem BC/BS dictated that as of January 1, 2019, all EDI transactions must route through Availity. This consolidation has meant that smaller vendors are forced to partner with larger ones, called intermediaries. Common intermediaries are Availity, Office Ally, and Change Healthcare which is owned by UnitedHealth Group, and had its own massive data breach in February 2024. 

None of us are 100% safe, and what’s scary is how little control we have. Especially if the systems we rely on are less than immediately forthcoming with customers and intermediaries.

What do I need to do if TriZetto is my clearinghouse?

If you think you might have been affected by the TriZetto breach, your obligations as a covered entity under HIPAA may involve contacting your EHR system to ask: 

1. Which clearinghouse(s) do you use?

2. Does it/they have any intermediary agreements with TriZetto?

3. If yes, which insurance payers are connected via TriZetto?

4. Has/have the clearinghouse(s) instituted any alternative routes for EDI transactions until TriZetto can confirm the integrity of their systems?

5. What, if any, notifications to patients/clients are the EHR’s responsibility? 

6. What notification actions is the EHR taking? 

Ask for the answers in writing via email. Or, ask if they’ve set up a FAQ / web page devoted to the incident response. Are they keeping it up to date via regular contact with TriZetto?

While we may not have much choice in terms of the EDI routes dictated by payers and intermediaries, it shouldn’t be too much to ask that the vendors we contract with be responsive and communicative when there are adverse events. Our own protected health information, and that of our clients, depends on honesty and transparency.

This blog is for informational purposes only and doesn’t constitute legal or compliance advice in any individual situation. 

URL: https://psychbillingcoach.com/news/discover-your-clearinghouse/

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

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

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DATE: March 19, 2026 at 06:54PM
SOURCE: PsychBilling Coach Billing Blog by Susan Frager
-------------------------------------------------

TITLE: Exhaustion and Systemic Accountability Failure

URL: https://psychbillingcoach.com/systemic-accountability-failure/

Battling insurance probably never was anyone’s idea of fun. But these days, we’re all exhausted from constant systemic accountability failures: insurance payers not taking responsibility for their mistakes.

The national companies are organizational monoliths grown from a sequence of mergers and acquisitions, with workflows now designed for their convenience, to retain as much profit as possible, and to disclaim responsibility. And with a few exceptions, even smaller plans seem to have followed suit. If it works for their larger, wealthier competitors, why not?

Most of the time, insurance companies are never held liable for their accountability failures. If companies do have to pay a regulatory fine here or there, most of the time it’s a small amount (to them!) that they probably regard as a routine cost of doing business. But none of that money ever gets passed to healthcare professionals as a form of compensation.

What will be the cost to us all, if clinicians are expected to carry on, year after year, conducting “business as usual,” under a system designed to ensure that as little money as possible is paid out for healthcare services?

Individual claims SNAFU’s

Every day, I consult with clinicians who come to me for help getting responses from systems which ignore them when they try to accomplish tasks the way they’re instructed to. For example…

Is it really necessary to write a letter to the CEO of a billion-dollar corporation in order to prove timely filing? Apparently it is, if the payer is Anthem BCBS and their sole inbound electronic gateway, Availity, has a systems issue.

Standard protocol is to send an appeal with proof of timely filing. On two occasions this year, one practice had incontrovertible clearinghouse proof of timely filing on days when Availity had publicly reported tech issues. It should be open and shut: complete the appeal form, and send it in with the proof of timely plus a copy of Availity’s issue report.

DENIED. “Not filed timely! The form letter showed no evidence anyone had looked at our attachments or even that a human being ever laid eyes on the appeal at all. No contact person listed.

(Did I mention that Anthem is part-owner of Availity?)

In another example, it was necessary to write to a CEO and the state’s insurance department before a health plan would agree that yes, an opted-out Medicare provider is forbidden *by law* to file claims to Medicare and that they owed a responsibility to their member to pay the secondary payer portion even without a Medicare remittance.

I continually work with clinicians to resolve:

• Credentialing and contracting that takes months and even when it’s supposedly “complete,” it’s not, and claims are denied or paid out of network.
•

• Electronic enrollments that take months.
•

• Single-case agreements that never quite coalesce between all the various departments for hassle-free claim payment.
•

• Addresses and other important provider data that gets updated 5 different ways but two years later the insurance company still hasn’t made the changes despite hassling clinicians for updates every 90 days.
•

• Insurance companies mysteriously not paying at the agreed-upon level of reimbursement. In some cases, even saying “sorry we put that in your contract, it was a mistake, but no, we won’t honor it.”
•

• Unexplained rate decreases with no prior notice.
•

• Clawbacks years after the fact because they couldn’t figure out Coordination of Benefits.
•

• Clinicians trying to terminate their contracts (wonder why?!?) with no response.
•

Would anything change, if executive teams were suddenly deluged with protests about their unworkable systems and accountability failures? I wonder. But if Round 1 ends in shenanigans, I find that kicking issues up to the executive level gets the job done!

Extreme examples of systemic accountability failure

Remember the 2022-2024 massive clawbacks from out of network LCSW’s accepting United Healthcare Medicare? United paid for 2 years at 100% of Medicare, when LCSW’s are supposed to receive 75%. No one could fight the clawbacks because Medicare fees are determined by the government. To knowingly retain a payment from federal healthcare funds that you aren’t entitled to is a serious offense called a reverse false claim.

It wasn’t the fact of the overpayment that was in dispute; what struck me was how United never experienced consequences for their accountability failure. Shouldn’t the federal government have been able to intervene? This wasn’t a small, localized issue affecting one or two people. It was a national accountability failure that was allowed to continue for a two-year period. Shouldn’t there have been some sort of penalty? Which, if there was any justice, could have been distributed among the clinicians affected by United’s negligence, since the fines would have come from United’s profits, not the Medicare trust fund.

Saying “Sorry for the inconvenience” on a form letter demanding a clawback just doesn’t cut it.

More recently, the TRICARE T-5 implementation beginning January 2025 was, and continues to be, a disaster even 15 months later. The extent of the systemic accountability failure was so extreme, it made the national news. There’s now a very active Facebook group for mental health clinicians struggling with TRICARE. Clinicians I worked with encountered some or all of these issues:

• Contracts not activated for months. When they were, they contained inaccurate information.
•

• Claims taking months to begin to pay.
•

• Then paying at the wrong reimbursement rate.
•

• Paying out of network instead of in-network for months, resulting in unexpected clawbacks for thousands of dollars.
•

• Applying an outdated standard that all counselors be required to have physician referrals and supervision.
•

• EDI enrollments that took months to approve.
•

What consequences have Humana and TriWest faced? I’m not aware of any, to date. According to a March 5, 2026 article on the American Physical Therapy Association page, Congress has asked for a report on the situation, due by March 31st. The report is to include issues of critical importance to the clinician community:

• Causes of TRICARE payment delays
•

• Reasons clinicians have left TRICARE’s network
•

• Average claim processing times
•

But Congressional inquiries typically drag on and on. And even if Congress does eventually hold Humana and/or TriWest accountable, how does that help healthcare professionals who are suffering financial losses today? If there are fines, the money goes to the US Treasury. Not helpful for clinicians trying to operate a small private practice, pay bills, and earn enough to live.

Short of litigation, I know of no avenue for financial remediation to providers who are victims of systemic accountability failure. And who has the resources or energy for lawsuits?

Is it any wonder that mental health clinicians burn out, exhausted from the continual fighting? Staying out of network or leaving panels, if you can sustain an out of network practice, is an understandable choice.

Can we return to balance?

Clinicians can have money clawed back for failing to document start and stop times of a therapy session, but billion-dollar corporations bungle national contracts affecting millions of lives without meaningful consequences. Aside from the basic injustice, how long can the American healthcare workforce survive under these conditions? It’s unsustainable. The mental health advocacy group Inseparable just published a mental health workforce report, and the picture is grim. Their main findings:

• 42% of the US population (144 million people) lives in a mental health professional shortage area (HPSA).

• Is your location considered a HPSA? Find out here. You’d be surprised I’ve seen mental health HPSA’s in non-rural areas.
•

•

• A majority of Americans do not receive treatment.

• About half of people experiencing mental health issues
•

• 80+% of people with substance use disorders
•

•

• In more than 30 states, mental health care is at least twice as likely to be out of network as treatment for medical conditions despite national and state parity laws.
•

The situation is correctible, but only if the systems which reward accountability failures on the part of insurance companies are rebalanced.

URL: https://psychbillingcoach.com/systemic-accountability-failure/

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: March 19, 2026 at 06:54PM
SOURCE: PsychBilling Coach by Susan Frager
-------------------------------------------------

TITLE: Exhaustion and Systemic Accountability Failure

URL: https://psychbillingcoach.com/systemic-accountability-failure/

Battling insurance probably never was anyone’s idea of fun. But these days, we’re all exhausted from constant systemic accountability failures: insurance payers not taking responsibility for their mistakes.

The national companies are organizational monoliths grown from a sequence of mergers and acquisitions, with workflows now designed for their convenience, to retain as much profit as possible, and to disclaim responsibility. And with a few exceptions, even smaller plans seem to have followed suit. If it works for their larger, wealthier competitors, why not?

Most of the time, insurance companies are never held liable for their accountability failures. If companies do have to pay a regulatory fine here or there, most of the time it’s a small amount (to them!) that they probably regard as a routine cost of doing business. But none of that money ever gets passed to healthcare professionals as a form of compensation.

What will be the cost to us all, if clinicians are expected to carry on, year after year, conducting “business as usual,” under a system designed to ensure that as little money as possible is paid out for healthcare services?

Individual claims SNAFU’s

Every day, I consult with clinicians who come to me for help getting responses from systems which ignore them when they try to accomplish tasks the way they’re instructed to. For example…

Is it really necessary to write a letter to the CEO of a billion-dollar corporation in order to prove timely filing? Apparently it is, if the payer is Anthem BCBS and their sole inbound electronic gateway, Availity, has a systems issue.

Standard protocol is to send an appeal with proof of timely filing. On two occasions this year, one practice had incontrovertible clearinghouse proof of timely filing on days when Availity had publicly reported tech issues. It should be open and shut: complete the appeal form, and send it in with the proof of timely plus a copy of Availity’s issue report.

DENIED. “Not filed timely! The form letter showed no evidence anyone had looked at our attachments or even that a human being ever laid eyes on the appeal at all. No contact person listed.

(Did I mention that Anthem is part-owner of Availity?)

In another example, it was necessary to write to a CEO and the state’s insurance department before a health plan would agree that yes, an opted-out Medicare provider is forbidden *by law* to file claims to Medicare and that they owed a responsibility to their member to pay the secondary payer portion even without a Medicare remittance.

I continually work with clinicians to resolve:

• Credentialing and contracting that takes months and even when it’s supposedly “complete,” it’s not, and claims are denied or paid out of network.
•

• Electronic enrollments that take months.
•

• Single-case agreements that never quite coalesce between all the various departments for hassle-free claim payment.
•

• Addresses and other important provider data that gets updated 5 different ways but two years later the insurance company still hasn’t made the changes despite hassling clinicians for updates every 90 days.
•

• Insurance companies mysteriously not paying at the agreed-upon level of reimbursement. In some cases, even saying “sorry we put that in your contract, it was a mistake, but no, we won’t honor it.”
•

• Unexplained rate decreases with no prior notice.
•

• Clawbacks years after the fact because they couldn’t figure out Coordination of Benefits.
•

• Clinicians trying to terminate their contracts (wonder why?!?) with no response.
•

Would anything change, if executive teams were suddenly deluged with protests about their unworkable systems and accountability failures? I wonder. But if Round 1 ends in shenanigans, I find that kicking issues up to the executive level gets the job done!

Extreme examples of systemic accountability failure

Remember the 2022-2024 massive clawbacks from out of network LCSW’s accepting United Healthcare Medicare? United paid for 2 years at 100% of Medicare, when LCSW’s are supposed to receive 75%. No one could fight the clawbacks because Medicare fees are determined by the government. To knowingly retain a payment from federal healthcare funds that you aren’t entitled to is a serious offense called a reverse false claim.

It wasn’t the fact of the overpayment that was in dispute; what struck me was how United never experienced consequences for their accountability failure. Shouldn’t the federal government have been able to intervene? This wasn’t a small, localized issue affecting one or two people. It was a national accountability failure that was allowed to continue for a two-year period. Shouldn’t there have been some sort of penalty? Which, if there was any justice, could have been distributed among the clinicians affected by United’s negligence, since the fines would have come from United’s profits, not the Medicare trust fund.

Saying “Sorry for the inconvenience” on a form letter demanding a clawback just doesn’t cut it.

More recently, the TRICARE T-5 implementation beginning January 2025 was, and continues to be, a disaster even 15 months later. The extent of the systemic accountability failure was so extreme, it made the national news. There’s now a very active Facebook group for mental health clinicians struggling with TRICARE. Clinicians I worked with encountered some or all of these issues:

• Contracts not activated for months. When they were, they contained inaccurate information.
•

• Claims taking months to begin to pay.
•

• Then paying at the wrong reimbursement rate.
•

• Paying out of network instead of in-network for months, resulting in unexpected clawbacks for thousands of dollars.
•

• Applying an outdated standard that all counselors be required to have physician referrals and supervision.
•

• EDI enrollments that took months to approve.
•

What consequences have Humana and TriWest faced? I’m not aware of any, to date. According to a March 5, 2026 article on the American Physical Therapy Association page, Congress has asked for a report on the situation, due by March 31st. The report is to include issues of critical importance to the clinician community:

• Causes of TRICARE payment delays
•

• Reasons clinicians have left TRICARE’s network
•

• Average claim processing times
•

But Congressional inquiries typically drag on and on. And even if Congress does eventually hold Humana and/or TriWest accountable, how does that help healthcare professionals who are suffering financial losses today? If there are fines, the money goes to the US Treasury. Not helpful for clinicians trying to operate a small private practice, pay bills, and earn enough to live.

Short of litigation, I know of no avenue for financial remediation to providers who are victims of systemic accountability failure. And who has the resources or energy for lawsuits?

Is it any wonder that mental health clinicians burn out, exhausted from the continual fighting? Staying out of network or leaving panels, if you can sustain an out of network practice, is an understandable choice.

Can we return to balance?

Clinicians can have money clawed back for failing to document start and stop times of a therapy session, but billion-dollar corporations bungle national contracts affecting millions of lives without meaningful consequences. Aside from the basic injustice, how long can the American healthcare workforce survive under these conditions? It’s unsustainable. The mental health advocacy group Inseparable just published a mental health workforce report, and the picture is grim. Their main findings:

• 42% of the US population (144 million people) lives in a mental health professional shortage area (HPSA).

• Is your location considered a HPSA? Find out here. You’d be surprised I’ve seen mental health HPSA’s in non-rural areas.
•

•

• A majority of Americans do not receive treatment.

• About half of people experiencing mental health issues
•

• 80+% of people with substance use disorders
•

•

• In more than 30 states, mental health care is at least twice as likely to be out of network as treatment for medical conditions despite national and state parity laws.
•

The situation is correctible, but only if the systems which reward accountability failures on the part of insurance companies are rebalanced.

URL: https://psychbillingcoach.com/systemic-accountability-failure/

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: February 12, 2026 at 01:47AM
SOURCE: PsychBilling Coach In the News by Susan Frager
-------------------------------------------------

TITLE: 2025 Insurance Profits: How much is enough?

URL: https://psychbillingcoach.com/news/2025-insurance-profits/

I’m sure it’s completely coincidental that insurance profits for 2025 weren’t released until after the entertaining (but probably performative) Congressional hearing that took place on January 22nd, where the CEO’s of Anthem BC/BS, United, Cigna, Aetna, and Blue Shield California faced a congressional panel who skewered them. None was more vehement than Dr. Greg Murphy (R-NC).

It was 9 hours of political theater, covering everything from bloated CEO salaries, high premiums and denial rates, pharmacy scams, and prior authorization.

And then there’s the medical-loss ratio profit schemes resulting from vertical integration (where the insurers own doctors, hospitals & pharmacy benefit managers in addition to being the insurer). Here’s AOC cheerfully telling the Aetna/CVS CEO that she’s fully aware of what’s going on:

“…the health insurance gets a cut, the pharmacy benefit manager gets a cut, the drug manufacturer gets a cut, and the patient gets screwed.”

Can’t put it more plainly than that! If you think vertical integration and medical-loss ratio money shenanigans don’t apply to us in mental health, think again!

The 2025 profit reports trickled out over the following two weeks (2025 CEO compensation isn’t yet available).

Sources:

Aetna

Anthem

Cigna

United

But apparently Wall Street isn’t impressed by these insurance profits?

Everyday people would be thrilled with $2.9 billion. But investors are underwhelmed as they probe beneath the surface of the reported insurance profits and look ahead to future insurance profits. In 2025, the percentages of premium payments reported by these 4 payers that were used to pay claims (the “medical loss ratio”) were quite a bit higher than last year.

• Aetna 94.8% (2025) 92.5% (2024)
•
• Anthem 90% (2025) 88.5% (2024)
•
• Cigna 83.7-84.7% (2025) 83.2% (2024)
•
• United 88.9% (2025) 85.5% (2024)
•

(Of course, no one’s talking about how much of that money is going into another pocket to overpay wholly-owned subsidiaries, or entities in whom they have an investment relationship. But that’s a different blog!)

Higher medical loss ratios are great for us as clinicians and clients it means claims are being paid. Not so for Wall Street. Health insurers aren’t like most “products,” where companies get richer the more the product is used. It’s the exact opposite insurance profits most when we don’t use the product, i.e. file a claim.

Publicly-traded companies in all industries are expected to generate healthy year-over-year profits. And in the last 10-15 years, American health insurers performed to expectations. They gobbled up pharmacy benefit managers, created profitable health services divisions such as Optum, Evernorth, and Carelon, bought physician practices and facilities. It’s often been asserted that United HealthGroup employs, either directly or indirectly, about 10% of American physicians currently in practice.

But that unchecked expansion appears to be reaching its limit.

Failure to renew the expanded ACA subsidies, and the resulting astronomical premium increases, is likely to result in healthier people deciding to risk not being insured. Or to scale back to Bronze or Catastrophic policies to keep premiums “affordable.” People who may have initially enrolled in the Marketplace for 2026 may begin to drop coverage as the year progresses -so keep re-verifying your clients’ eligibility!

These developments in 2026 Marketplace coverage are likely to impact insurance profits negatively:

• Fewer enrollees paying less in total premiums.
•
• Medical loss ratio soars higher, as remaining ACA enrollees are people with more serious health conditions who can’t risk being uninsured. Claims will be more expensive, from a smaller pool of revenue.
•

The “One Big Beautiful Bill,” with its focus on imposing Medicaid work requirements and reducing the numbers of people eligible for Medicaid, will also heavily impact payers whose focus has been on Medicaid managed care. The people most likely to remain insured through Medicaid will be those most in need of expensive care. Again: fewer insurance profits as higher and higher percentages of premium dollars are (gasp!) actually having to be spent paying claims.

Then there’s “Medicare not-such-an-Advantage-after-all.” For years, taxpayers have been defrauded to the tune of about $75 billion per year in overpayments, thanks to those pesky risk adjustment audits you keep getting. How is it, then, that there have been no clawbacks for almost 20 years since 2007? Each time the feds have tried to claw back, they’re met with lawsuits or appeals from the insurance payers, and have backed down. Supposedly, this time, clawbacks from payers will begin “soon.” Being originally from Missouri, I’ll believe it when I see it happen.

Medicare “Advantage” has been a gravy train with billions in insurance profits for over 2 decades. But the train may finally have reached the end of the line: on January 26, CMS announced that for 2027, there would only be a 0.09% rate increase to the payers, compared to the 5% jump from 2025 to 2026. Wall Street reacted accordingly. Stock prices tanked, dropping 5-13% in a single day.

These numbers are incomprehensible to most of us. A billion is an almost inconceivable amount. If I had a million dollars (I wish, right?), and I spent $1,000 per day, it would take me 3 years to spend it all. But if I had a billion dollars and spent $1,000 per day, I’d need more than several lifetimes to spend it: 2,739 years and 7 months, to be exact.

So how much is enough? How much longer can our healthcare system function under the status quo before it implodes on us?

The latest development: on February 10, two senators from opposite ends of the political divide announced that they’d joined forces, introducing a bill to “Break Up Big Medicine.” 

I guess we’ll see what develops.

URL: https://psychbillingcoach.com/news/2025-insurance-profits/

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: January 19, 2026 at 02:03AM
SOURCE: PsychBilling Coach Billing Blog by Susan Frager
-------------------------------------------------

TITLE: Defend against Continuity of Care denials!

URL: https://psychbillingcoach.com/continuity-of-care-denials/

Clients are soon going to report New Year’s insurance changes, and you may suddenly be out of network. But, they might be entitled to “Continuity of Care” extensions of in-network coverage for a period of time. The reason for the network status change could be due to:

• Provider/Facility Contract Termination
•

• Policy network change (perhaps from a PPO to a HMO network)
•

• Previous policy no longer available (for instance, on the ACA Marketplace or Medicare Advantage)
•

• Employer group changes policies and the new network doesn’t include the treating clinician.
•

Sometimes Continuity of Care extensions of in-network benefits are mandated by the No Surprises Act, sometimes by state law, or even negotiated by your client’s employer. For our purposes, it’s not necessary to know who’s granting the extension just whether the client has access to it.

What do I do if I’m suddenly out of network?

It’s a difficult situation and presents an ethical dilemma. You have a clinical and professional responsibility not to abandon your client. But the reality is that out of network might be unaffordable for them! Yet, you’re not a charity. You’re responsible for protecting your time and your income and there’s no shame in recognizing this fact and acting on your own behalf.

When you discover that you’re no longer in-network, start by taking these 4 steps, in order:

• Alert your client that they might have “continuity of care in-network coverage” for at least the first 90 days of the year.
•

• To request access this extension of in-network benefits, the client will need to call their insurance company or login to their portal.
•

• If the client reports back to say that they have “continuity of care in-network coverage,” ask them for written documentation.
•

• Begin the Single-Case Agreement process.
•

Isn’t Continuity of Care the same as a Single-Case Agreement?

They’re related, but aren’t the same.

A single-case agreement is essentially mini-credentialing, joining the insurance panel for one specific client. Continuity of Care is one of the most common reasons a single-case agreement is given.

Single-case agreements are also granted for other reasons, such as a network gap due to clinical specialty, no one’s accepting new clients, cultural/linguistic needs, etc. Sometimes, single-case agreements are extended because a clinician is in the process of undergoing credentialing for full admission to the panel.

Payers who allow supervisory billing also have an obligation to extend in-network benefits for the same continuity of care reasons. When a provisionally-licensed clinician obtains full licensure, they can no longer legally bill under their previous supervisor. It’s the newly-licensed clinician is the one who has the relationship with the client not the former supervisor. This, by the way, is the primary reason why supervisory billing is NOT the same as “incident-to.”

Not pairing a mandatory extension of in-network benefits with a single-case agreement is an invitation for claims to be denied.

“Continuity of Care” in-network extensions are usually doomed to fail without Single-Case Agreements!

Why?

Claims are adjudicated using artificial intelligence. With no human evaluating the claim, the system just sees a tax id/NPI combination that’s out-of-network. Even with a single-case agreement authorization number on the claim form, that out-of-network TIN/NPI combo often seems to control the outcome.

All other things being equal, single-case agreement claims are more likely to be denied than routine in-network claims. Out-of-network professionals tend to have a much harder time than their in-network peers: in order to get single-case agreement claims paid, repeated calls have to be made, and appeals/disputes filed, to try to reach a human with the authority to override the denials. That’s not easy! If you’re spinning your wheels in such a situation, you may have to resort to badass executive complaint methods. Which are available to you even out-of-network!

How a single-case agreement works

Once the insurance payer approves a single-case agreement (regardless of the reason), a shortened form of basic credentialing takes place. The insurance payer obtains the following information.

• Tax ID / W9
•

• License
•

• Malpractice insurance info
•

• Signature on a modified “contract” or “letter of agreement.” The document should include the reimbursement rates being offered, plus the usual obligations & contractual protections for clients that would be true of any in-network provider:

• Accepting assignment
•

• Filing claims
•

• No balance-billing
•

• “Timely” filing
•

•

When the above documents are received and loaded into the claims system, the care manager approving the single-case agreement issues an authorization letter for whatever period of time and/or number of visits will be covered at the “in-network” benefit level.

If you’re in the process of obtaining a single-case agreement, wait to file your claims until everything is in place.

Why Continuity of Care may not routinely offer single-case agreements

In the event of a network termination during a course of treatment, insurers are required to send automated letters to clients stating “[provider name] is out-of-network as of [date], here are your options for continuing your care” and listing the instructions to follow if the client wants to continue to obtain in-network level benefits for the transition period.

As with anything else insurance, clients are given impossible to understand instructions, and usually not in a timely manner. I recently received a Continuity of Care letter in my mailbox last month, dated August 2025, about a provider who left a family member’s network. Hmmm…you get Continuity of Care benefits for up to 90 days, but it takes 120 days to notify you!?! Right.

Typically, it’s the client who’s responsible for notifying the insurer that they want to utilize their Continuity of Care benefit. It’s very unusual for an insurance company to grant Continuity of Care benefits on the basis of a provider request. But when the client accesses their Continuity of Care benefits, it’s handled by Member Services. The client then typically receives a letter confirming that their care with the clinician in question will be paid at the in-network benefit level.

See the set-up here?! The Member Services department doesn’t always trigger the formal single-case agreement process, which is typically handled by Provider Services.

Then the client thinks they’re good, and that’s all there is to it.

Um…no. You, the clinician, aren’t being set up to succeed here. Quite the opposite.

If you think about what’s required to set up a single-case agreement, as described above, you’ll realize that single case agreements consume a lot of employee time the insurance companies have to pay for. (And they don’t like to pay for anything!)

What if the payer refuses to give a single-case agreement?

If you don’t have the time or energy to engage in a fight to obtain the single-case agreement, there are a few options.

• Collect either your full rate or your previous in-network reimbursement rate at the session and furnish a superbill. That’s now your right as an out-of-network clinician. (Sliding scales aren’t generally a good idea when using insurance.)
•

• Consider referring the client to one of the superbill-submitting services that help clients get reimbursed. It typically doesn’t cost you anything unless you choose to shoulder the cost as a courtesy for the client.
•

• You can submit a “non-assigned” claim, meaning you direct the insurance payer to pay the client. This is done by leaving box 13 or its electronic equivalent blank, by checking “no” in box 27, and by listing the full amount paid in box 29.

• One problem with “courtesy” billing (non-assigned claims) is that insurance payers may send you the money anyway. Why? Because it’s easier to claw back from you than from a client.
•

• Another typical problem is interference from companies such as Multiplan/Claritev, who try to reduce the rates you’re paid.
•

•

The problem with any of the above strategies, of course, is that they all require the client to pay the full billed charge at the time of the session which not all clients can afford to do. Especially if there’s likely to be a longer-than-usual delay in obtaining in-network level reimbursement.

Regardless of the reason they’re granted, single-case agreements are great for clients but they may be challenging for you. You may not have a choice if you left the network continuity of care for your clients is a must. But if you’re now out-of-network for reasons you didn’t control, or if the single-case agreement was granted due to network inadequacy, you’ll want to learn all you can about what accepting a single-case agreement entails before taking it on. Or discuss other options with your client.

URL: https://psychbillingcoach.com/continuity-of-care-denials/

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: January 19, 2026 at 02:03AM
SOURCE: PsychBilling Coach by Susan Frager
-------------------------------------------------

TITLE: Defend against Continuity of Care denials!

URL: https://psychbillingcoach.com/continuity-of-care-denials/

Clients are soon going to report New Year’s insurance changes, and you may suddenly be out of network. But, they might be entitled to “Continuity of Care” extensions of in-network coverage for a period of time. The reason for the network status change could be due to:

• Provider/Facility Contract Termination
•

• Policy network change (perhaps from a PPO to a HMO network)
•

• Previous policy no longer available (for instance, on the ACA Marketplace or Medicare Advantage)
•

• Employer group changes policies and the new network doesn’t include the treating clinician.
•

Sometimes Continuity of Care extensions of in-network benefits are mandated by the No Surprises Act, sometimes by state law, or even negotiated by your client’s employer. For our purposes, it’s not necessary to know who’s granting the extension just whether the client has access to it.

What do I do if I’m suddenly out of network?

It’s a difficult situation and presents an ethical dilemma. You have a clinical and professional responsibility not to abandon your client. But the reality is that out of network might be unaffordable for them! Yet, you’re not a charity. You’re responsible for protecting your time and your income and there’s no shame in recognizing this fact and acting on your own behalf.

When you discover that you’re no longer in-network, start by taking these 4 steps, in order:

• Alert your client that they might have “continuity of care in-network coverage” for at least the first 90 days of the year.
•

• To request access this extension of in-network benefits, the client will need to call their insurance company or login to their portal.
•

• If the client reports back to say that they have “continuity of care in-network coverage,” ask them for written documentation.
•

• Begin the Single-Case Agreement process.
•

Isn’t Continuity of Care the same as a Single-Case Agreement?

They’re related, but aren’t the same.

A single-case agreement is essentially mini-credentialing, joining the insurance panel for one specific client. Continuity of Care is one of the most common reasons a single-case agreement is given.

Single-case agreements are also granted for other reasons, such as a network gap due to clinical specialty, no one’s accepting new clients, cultural/linguistic needs, etc. Sometimes, single-case agreements are extended because a clinician is in the process of undergoing credentialing for full admission to the panel.

Payers who allow supervisory billing also have an obligation to extend in-network benefits for the same continuity of care reasons. When a provisionally-licensed clinician obtains full licensure, they can no longer legally bill under their previous supervisor. It’s the newly-licensed clinician is the one who has the relationship with the client not the former supervisor. This, by the way, is the primary reason why supervisory billing is NOT the same as “incident-to.”

Not pairing a mandatory extension of in-network benefits with a single-case agreement is an invitation for claims to be denied.

“Continuity of Care” in-network extensions are usually doomed to fail without Single-Case Agreements!

Why?

Claims are adjudicated using artificial intelligence. With no human evaluating the claim, the system just sees a tax id/NPI combination that’s out-of-network. Even with a single-case agreement authorization number on the claim form, that out-of-network TIN/NPI combo often seems to control the outcome.

All other things being equal, single-case agreement claims are more likely to be denied than routine in-network claims. Out-of-network professionals tend to have a much harder time than their in-network peers: in order to get single-case agreement claims paid, repeated calls have to be made, and appeals/disputes filed, to try to reach a human with the authority to override the denials. That’s not easy! If you’re spinning your wheels in such a situation, you may have to resort to badass executive complaint methods. Which are available to you even out-of-network!

How a single-case agreement works

Once the insurance payer approves a single-case agreement (regardless of the reason), a shortened form of basic credentialing takes place. The insurance payer obtains the following information.

• Tax ID / W9
•

• License
•

• Malpractice insurance info
•

• Signature on a modified “contract” or “letter of agreement.” The document should include the reimbursement rates being offered, plus the usual obligations & contractual protections for clients that would be true of any in-network provider:

• Accepting assignment
•

• Filing claims
•

• No balance-billing
•

• “Timely” filing
•

•

When the above documents are received and loaded into the claims system, the care manager approving the single-case agreement issues an authorization letter for whatever period of time and/or number of visits will be covered at the “in-network” benefit level.

If you’re in the process of obtaining a single-case agreement, wait to file your claims until everything is in place.

Why Continuity of Care may not routinely offer single-case agreements

In the event of a network termination during a course of treatment, insurers are required to send automated letters to clients stating “[provider name] is out-of-network as of [date], here are your options for continuing your care” and listing the instructions to follow if the client wants to continue to obtain in-network level benefits for the transition period.

As with anything else insurance, clients are given impossible to understand instructions, and usually not in a timely manner. I recently received a Continuity of Care letter in my mailbox last month, dated August 2025, about a provider who left a family member’s network. Hmmm…you get Continuity of Care benefits for up to 90 days, but it takes 120 days to notify you!?! Right.

Typically, it’s the client who’s responsible for notifying the insurer that they want to utilize their Continuity of Care benefit. It’s very unusual for an insurance company to grant Continuity of Care benefits on the basis of a provider request. But when the client accesses their Continuity of Care benefits, it’s handled by Member Services. The client then typically receives a letter confirming that their care with the clinician in question will be paid at the in-network benefit level.

See the set-up here?! The Member Services department doesn’t always trigger the formal single-case agreement process, which is typically handled by Provider Services.

Then the client thinks they’re good, and that’s all there is to it.

Um…no. You, the clinician, aren’t being set up to succeed here. Quite the opposite.

If you think about what’s required to set up a single-case agreement, as described above, you’ll realize that single case agreements consume a lot of employee time the insurance companies have to pay for. (And they don’t like to pay for anything!)

What if the payer refuses to give a single-case agreement?

If you don’t have the time or energy to engage in a fight to obtain the single-case agreement, there are a few options.

• Collect either your full rate or your previous in-network reimbursement rate at the session and furnish a superbill. That’s now your right as an out-of-network clinician. (Sliding scales aren’t generally a good idea when using insurance.)
•

• Consider referring the client to one of the superbill-submitting services that help clients get reimbursed. It typically doesn’t cost you anything unless you choose to shoulder the cost as a courtesy for the client.
•

• You can submit a “non-assigned” claim, meaning you direct the insurance payer to pay the client. This is done by leaving box 13 or its electronic equivalent blank, by checking “no” in box 27, and by listing the full amount paid in box 29.

• One problem with “courtesy” billing (non-assigned claims) is that insurance payers may send you the money anyway. Why? Because it’s easier to claw back from you than from a client.
•

• Another typical problem is interference from companies such as Multiplan/Claritev, who try to reduce the rates you’re paid.
•

•

The problem with any of the above strategies, of course, is that they all require the client to pay the full billed charge at the time of the session which not all clients can afford to do. Especially if there’s likely to be a longer-than-usual delay in obtaining in-network level reimbursement.

Regardless of the reason they’re granted, single-case agreements are great for clients but they may be challenging for you. You may not have a choice if you left the network continuity of care for your clients is a must. But if you’re now out-of-network for reasons you didn’t control, or if the single-case agreement was granted due to network inadequacy, you’ll want to learn all you can about what accepting a single-case agreement entails before taking it on. Or discuss other options with your client.

URL: https://psychbillingcoach.com/continuity-of-care-denials/

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: January 05, 2026 at 02:12PM
SOURCE: PsychBilling Coach Billing Blog by Susan Frager
-------------------------------------------------

TITLE: Eliminate reimbursement rate mysteries!

URL: https://psychbillingcoach.com/end-reimbursement-rate-mysteries/

In mental health private practice, reimbursement rate mysteries plague us all:

• The insurance company won’t tell me what their reimbursement rates are until after I’m credentialed and signed the contract! So how do I decide if I want to join?
•

• Many of my clients need to use insurance. If only I could negotiate a reasonable reimbursement rate! I hear stories that some professionals get better rates, but I can’t figure out how!
•

• I can’t find/wasn’t sent a contract with a fee schedule! Or, over the years insurance panels updated my rates. But they don’t send notices of updates anymore. Sometimes they merged with another company and it’s not clear if I’m getting paid what I should be. Can I find out if I’m being underpaid?
•

• I’m a group practice owner. The venture-capital platforms are killing my business because they can pay better and credential much faster. Is the same procedure delivered through a platform really worth so much more than what my group is reimbursed? I can’t even effectively advocate for my group because I don’t have the reimbursement data! I don’t know how much of a raise I can get away with asking for.
•

What if you could discover what insurance pays everyone in your market for the same CPT code?

You can! A law passed at the end of 2020, called the Transparency in Coverage, or Price Transparency law, mandated release of the reimbursement rate mysteries beginning July 1, 2022, in what they call “machine-readable files.”

The government’s idea was that by publicizing the reimbursement rate mysteries, it would somehow enable consumers to compare prices for healthcare services and shop around for the best deal so that market forces could bring down healthcare costs. But the US healthcare system isn’t exactly a free market. If only one hospital in your city is in-network with your insurance, it doesn’t matter if they charge the most for the surgery you need. You’re still going to go there because to go out of network would be much more costly for you, even at a “lower” price.

Regardless, the reimbursement rate mysteries are quietly released every month in order to satisfy the law.

How do I get my hands on reimbursement rate data?!

Naturally, it’s not as simple as just logging onto Availity or another payer portal and downloading it. Oh no. This dataset is estimated to be 500 terabytes to 1 petabyte. To put that into perspective, 1 petabyte of printed data is about 500 billion pages 100 times more pages than all the volumes in the Library of Congress.

CMS offers oh-so-unhelpful directions on obtaining reimbursement data:

Specific technology may be needed to download and read these files given their size and complexity.

The Departments of Health and Human Services, Labor, and the Treasury envision that third-party developers and other entities will download, process, and compile this data, creating more advanced price transparency tools…

How will this help consumers? That remains to be seen. But we can use this data to help ourselves! Because I now have access to this tool. Naturally, there’s a cost. Those “third-party developers and other entities” always have to be paid, in US healthcare.

But that cost might be worth it, many times over.

Insurance won’t reveal rates prior to paneling

Reimbursement rate mysteries are a thing of the past even if insurance payers still want you to believe otherwise.

You don’t have to be currently contracted to obtain reimbursement data. We can do a market analysis to answer the basic question: “What’s the range of rates that Aetna, United, Cigna, BC/BS pays in your zip code?” From there, it’s just math: are these reimbursement rates adequate to sustain you in practice and earn the income you want? If the rates are lower than acceptable, at what point do you draw the line and say no to a contract?

Part of your decision about joining a panel might be to accommodate current clients whose insurance has changed. The rate may not be ideal, but at what level is it decent enough to participate, as long as you’re not overwhelmed by clients with that plan. Wouldn’t it be better to get reimbursement information before dealing with the hassles and delays of credentialing? Common sense (and the law) say yes, even while insurers still stonewall, playing power games.

Negotiating more realistic reimbursement rates

Wouldn’t you love to be able to write this sentence? “Dear Insurance Company: My request for $150 for a 90837 is justified by what you’re already paying at least 50% of the time to other clinicians with my specialty in my zip code, according to the Transparency in Coverage machine-readable files.”

You might find you’re able to!

It’s a bit more complicated than that, of course. You still have to show how your practice is worth inclusion in the top-reimbursed 50% of the network, rather than at the bottom. Need arguments to persuade insurers?

Are you being underpaid?

Insurance plans underpay often. By not having a clear fee schedule telling you what you’re supposed to earn, you’re unable to fight underpayments.

Once you know what you’re supposed to earn, a good billing platform will allow you to enter the insurer’s fee schedule(s) and can generate automated reports showing where you’re being underpaid.

Underpayments may seem too insignificant to challenge until you start adding up what you lose over a year’s time. What if an insurer was underpaying you by $3 per session? That seems too trivial of a battle to fight until you realize that you saw 4 clients of theirs, 4 times a month, for a total of $576 underpayment last year.

The price transparency data often reveals that you’ve been paid varying amounts for the same procedure. Some of these variances can be explained by insurers’ practice of reimbursing the same procedure differently according to whether the policy is HMO, PPO, on or off the ACA Marketplace, a large self-funded employer group, small employer group, etc.

But if the insurer isn’t clearly explaining the differences in the fee schedules, AND giving you the opportunity to identify which clients belong to which fee schedule, what then? Or maybe they’re giving you all the fee schedules, but the documents and terms used are so incomprehensible that you can’t even answer the simple question “How much should I be getting for a 90837?”

Insurers voluntarily release reimbursement data for commercial employer and individual policies only to comply with federal law. They aren’t exactly motivated to be forthcoming about it with you not without considerable effort on your part possibly involving an Executive Badass complaint. Medicare Advantage, Medicaid, and Tricare/VA reimbursement rate mysteries still need to be addressed with reference to the published federal, state, or military fee schedules.

Groups competing with the platforms

Sometimes the data from the machine-readable Transparency in Coverage files shows that even though the venture-capital platform may be paying you $10-25 more than they would if you were contracted in your private practice, the insurance company is paying the venture-capital platform significantly more. Especially if said insurance company is also an investor in the venture-capital platform. (Just a coincidence, I’m sure…)

And as I previously revealed, in that situation your clients may be overpaying while having to satisfy their deductible but little if any of that extra money goes to you.

In a group setting, the strategy is slightly different. It begins with demonstrating to clinicians how working with you provides a more clinically rewarding and ethical practice life to say nothing of also decreasing isolation and potential burnout. Once you can attract -and retain- good clinicians, the next step is a program of measuring client outcomes, to show insurance payers how your group’s quality of care decreases medical expenditures associated with behavioral health conditions. Managed care executives don’t grant rate increases without this information and you have to show them, not just tell them.

It would be more satisfying to engage in a frontal assault and fight for justice: everyone in the same market should be paid the same rate regardless of ownership or size. But current laws forbid unionizing or similar direct advocacy by private practitioners, so I can’t play Norma Rae until or unless that changes. (Professional associations, are you listening?)

Price transparency data that shines light on insurance payer reimbursement rate mysteries is the best tool we have, at the moment, to improve profitability of behavioral health clinicians in 2026.

Ready to get started?

URL: https://psychbillingcoach.com/end-reimbursement-rate-mysteries/

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: January 05, 2026 at 02:12PM
SOURCE: PsychBilling Coach by Susan Frager
-------------------------------------------------

TITLE: Eliminate reimbursement rate mysteries!

URL: https://psychbillingcoach.com/end-reimbursement-rate-mysteries/

In mental health private practice, reimbursement rate mysteries plague us all:

• The insurance company won’t tell me what their reimbursement rates are until after I’m credentialed and signed the contract! So how do I decide if I want to join?
•

• Many of my clients need to use insurance. If only I could negotiate a reasonable reimbursement rate! I hear stories that some professionals get better rates, but I can’t figure out how!
•

• I can’t find/wasn’t sent a contract with a fee schedule! Or, over the years insurance panels updated my rates. But they don’t send notices of updates anymore. Sometimes they merged with another company and it’s not clear if I’m getting paid what I should be. Can I find out if I’m being underpaid?
•

• I’m a group practice owner. The venture-capital platforms are killing my business because they can pay better and credential much faster. Is the same procedure delivered through a platform really worth so much more than what my group is reimbursed? I can’t even effectively advocate for my group because I don’t have the reimbursement data! I don’t know how much of a raise I can get away with asking for.
•

What if you could discover what insurance pays everyone in your market for the same CPT code?

You can! A law passed at the end of 2020, called the Transparency in Coverage, or Price Transparency law, mandated release of the reimbursement rate mysteries beginning July 1, 2022, in what they call “machine-readable files.”

The government’s idea was that by publicizing the reimbursement rate mysteries, it would somehow enable consumers to compare prices for healthcare services and shop around for the best deal so that market forces could bring down healthcare costs. But the US healthcare system isn’t exactly a free market. If only one hospital in your city is in-network with your insurance, it doesn’t matter if they charge the most for the surgery you need. You’re still going to go there because to go out of network would be much more costly for you, even at a “lower” price.

Regardless, the reimbursement rate mysteries are quietly released every month in order to satisfy the law.

How do I get my hands on reimbursement rate data?!

Naturally, it’s not as simple as just logging onto Availity or another payer portal and downloading it. Oh no. This dataset is estimated to be 500 terabytes to 1 petabyte. To put that into perspective, 1 petabyte of printed data is about 500 billion pages 100 times more pages than all the volumes in the Library of Congress.

CMS offers oh-so-unhelpful directions on obtaining reimbursement data:

Specific technology may be needed to download and read these files given their size and complexity.

The Departments of Health and Human Services, Labor, and the Treasury envision that third-party developers and other entities will download, process, and compile this data, creating more advanced price transparency tools…

How will this help consumers? That remains to be seen. But we can use this data to help ourselves! Because I now have access to this tool. Naturally, there’s a cost. Those “third-party developers and other entities” always have to be paid, in US healthcare.

But that cost might be worth it, many times over.

Insurance won’t reveal rates prior to paneling

Reimbursement rate mysteries are a thing of the past even if insurance payers still want you to believe otherwise.

You don’t have to be currently contracted to obtain reimbursement data. We can do a market analysis to answer the basic question: “What’s the range of rates that Aetna, United, Cigna, BC/BS pays in your zip code?” From there, it’s just math: are these reimbursement rates adequate to sustain you in practice and earn the income you want? If the rates are lower than acceptable, at what point do you draw the line and say no to a contract?

Part of your decision about joining a panel might be to accommodate current clients whose insurance has changed. The rate may not be ideal, but at what level is it decent enough to participate, as long as you’re not overwhelmed by clients with that plan. Wouldn’t it be better to get reimbursement information before dealing with the hassles and delays of credentialing? Common sense (and the law) say yes, even while insurers still stonewall, playing power games.

Negotiating more realistic reimbursement rates

Wouldn’t you love to be able to write this sentence? “Dear Insurance Company: My request for $150 for a 90837 is justified by what you’re already paying at least 50% of the time to other clinicians with my specialty in my zip code, according to the Transparency in Coverage machine-readable files.”

You might find you’re able to!

It’s a bit more complicated than that, of course. You still have to show how your practice is worth inclusion in the top-reimbursed 50% of the network, rather than at the bottom. Need arguments to persuade insurers?

Are you being underpaid?

Insurance plans underpay often. By not having a clear fee schedule telling you what you’re supposed to earn, you’re unable to fight underpayments.

Once you know what you’re supposed to earn, a good billing platform will allow you to enter the insurer’s fee schedule(s) and can generate automated reports showing where you’re being underpaid.

Underpayments may seem too insignificant to challenge until you start adding up what you lose over a year’s time. What if an insurer was underpaying you by $3 per session? That seems too trivial of a battle to fight until you realize that you saw 4 clients of theirs, 4 times a month, for a total of $576 underpayment last year.

The price transparency data often reveals that you’ve been paid varying amounts for the same procedure. Some of these variances can be explained by insurers’ practice of reimbursing the same procedure differently according to whether the policy is HMO, PPO, on or off the ACA Marketplace, a large self-funded employer group, small employer group, etc.

But if the insurer isn’t clearly explaining the differences in the fee schedules, AND giving you the opportunity to identify which clients belong to which fee schedule, what then? Or maybe they’re giving you all the fee schedules, but the documents and terms used are so incomprehensible that you can’t even answer the simple question “How much should I be getting for a 90837?”

Insurers voluntarily release reimbursement data for commercial employer and individual policies only to comply with federal law. They aren’t exactly motivated to be forthcoming about it with you not without considerable effort on your part possibly involving an Executive Badass complaint. Medicare Advantage, Medicaid, and Tricare/VA reimbursement rate mysteries still need to be addressed with reference to the published federal, state, or military fee schedules.

Groups competing with the platforms

Sometimes the data from the machine-readable Transparency in Coverage files shows that even though the venture-capital platform may be paying you $10-25 more than they would if you were contracted in your private practice, the insurance company is paying the venture-capital platform significantly more. Especially if said insurance company is also an investor in the venture-capital platform. (Just a coincidence, I’m sure…)

And as I previously revealed, in that situation your clients may be overpaying while having to satisfy their deductible but little if any of that extra money goes to you.

In a group setting, the strategy is slightly different. It begins with demonstrating to clinicians how working with you provides a more clinically rewarding and ethical practice life to say nothing of also decreasing isolation and potential burnout. Once you can attract -and retain- good clinicians, the next step is a program of measuring client outcomes, to show insurance payers how your group’s quality of care decreases medical expenditures associated with behavioral health conditions. Managed care executives don’t grant rate increases without this information and you have to show them, not just tell them.

It would be more satisfying to engage in a frontal assault and fight for justice: everyone in the same market should be paid the same rate regardless of ownership or size. But current laws forbid unionizing or similar direct advocacy by private practitioners, so I can’t play Norma Rae until or unless that changes. (Professional associations, are you listening?)

Price transparency data that shines light on insurance payer reimbursement rate mysteries is the best tool we have, at the moment, to improve profitability of behavioral health clinicians in 2026.

Ready to get started?

URL: https://psychbillingcoach.com/end-reimbursement-rate-mysteries/

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

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

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

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DATE: November 16, 2025 at 11:36PM
SOURCE: PsychBilling Coach by Susan Frager
-------------------------------------------------

TITLE: 3 Paving Stones of the Tech Platform Money Trail

URL: https://psychbillingcoach.com/tech-platform-money-trail/

Yes, it’s true. Insurance companies are investors in Alma, Headway, Rula, etc. Worse, following the tech platform money trail back to its origins, we uncover the same economic dynamics in behavioral health that now control all of American healthcare. It’s disheartening: mental health parity in all the wrong ways!

Most of us think of the tech platforms as having emerged seemingly overnight in response to the mental health crisis and urgent need for services via telehealth brought on by COVID. But in reality, that’s not exactly correct. Both Alma and Headway began prior to COVID, in 2018-2019, which means the tech platform money trail stretches back further in time. As in the medical field, there are three concepts which, together, form the paving stones of this money trail.

• Medical Loss Ratio
•

• Vertical Integration
•

• Transfer Pricing
•

Medical Loss Ratio

In insurance-speak, the Medical Loss Ratio (MLR) is the percentage of premium dollars directly used to pay claims and for quality improvement/disease management expenditures. Money the insurance payer collects that isn’t used for these purposes goes to pay their operating costs. And, of course, profit. Wall Street expects a hefty profit on top, to please shareholders. That profit has to come from somewhere.

The government has attempted to ensure consumers and taxpayers are protected by defining the minimum percentage of premium dollars that must be spent directly on healthcare activities:

• ACA-regulated commercial & marketplace plans: 85% MLR is required for “large groups” and 80% for individual & small group plans. (note: states can choose to raise the MLR requirements).

• If you’ve ever received a random check from your insurer referencing a “medical loss ratio rebate,” it’s because your insurance company failed to meet the MLR target. They’re required by law to give back the corresponding percentage of your premiums they failed to spend on claims.
•

•

• Medicare “Advantage” requires an 85% or higher MLR.

• Plans with lower than 85% MLR must refund CMS.
•

• Contrast this with Original Medicare, where in 2021 the administrative costs (since there’s no profit requirement) hovered around 1.3% of Medicare’s budget.
•

•

• Medicaid Managed Care also requires the MLR to be at least 85%.
•

Vertical Integration

Vertical integration describes the acquisition by insurance companies of non-insurance healthcare entities. This can be anything from electronic clearinghouses such as Change Healthcare, to imaging, pharmacy benefit managers, specialty physician practices, ambulatory surgery centers, urgent care, and even consumer-facing information products such as Healthgrades, Medical News Today, and PsychCentral: all owned by RVO Health who’s owned by (you guessed it) United HealthGroup.

United is the most egregious vertical integrator, with 2,694 subsidiary companies. Everyone’s heard the statistic that United employs about 10% of American physicians, but the list of 2,694 subsidiaries demonstrates that behavioral health isn’t exempt. At least 75 large behavioral health practices are listed, including some with familiar names, such as Refresh Mental Health.

But United isn’t the only culprit. Availity, the portal most of us who deal with insurance claims must use (and love to hate), started in 2001 as a joint venture between Florida Blue and Humana. It was then acquired in 2006 by HCSC, owner of 5 Blue Cross/Blue Shield plans. Elevance/Anthem (14 BC/BS plans), and BCBS Minnesota joined as co-owners of Availity in 2009.

The list of Elevance’s (Anthem; Carelon) subsidiaries reveals that they own NGS Federal, LLC, otherwise known as National Government Services, the Medicare Administrative Contractor for 10 states, as well as infusion centers, a sales consultancy for healthcare startups, various Medicaid managed care organizations, even a legal services company focusing on healthcare cost containment (interesting side note: following this hyperlink will take you to a LinkedIn page. If you click on About, and then the company’s website, http://www.4600boehm.com/, you end up at Carelon Payment Integrity). Small world, eh?

Likewise, the Cigna Group has their own healthcare pyramid. Notable subsidiaries of Cigna include one of the largest American Pharmacy Benefit Managers, Express Scripts, which even has its own associated pharmaceutical distribution arm. EviCore, revealed last year by ProPublica to be the AI giant behind “medical necessity” prior authorization denials, is also owned by Cigna.

Transfer Pricing

So what’s to keep United from paying Refresh Behavioral Health’s clinicians more for a 90837 than they would pay you in an independent private practice? What’s to keep them from paying more for a surgery at one of their own ambulatory surgery centers than they would for the same surgery performed at an independent hospital?

Nothing! A study published this month in Health Affairs found that UHG-owned providers were paid anywhere from 17-61% more than those not owned by United.

The phenomenon of paying more for the same service to a company under the same corporate umbrella is known as transfer pricing. The money just moves from one side of the house to the other. But, that money is spent on claims so it nevertheless counts toward satisfying the government’s Medical Loss Ratio requirements.

As a result of vertical integration, transfer pricing has been the means by which the large insurer-owned conglomerates have gotten around the government’s well-intentioned Medical Loss Ratio requirements. The authors of the Health Affairs study concluded that even just a 1% price increase to wholly-owned subsidiaries could lead to billions of dollars “saved” from having to be rebated back to consumers or the federal government. And where does this money go, instead?

Corporate Profits, of course.

Paving the Tech Platform Money Trail

So, back to our behavioral health corner of the healthcare world. I previously reported on insurance payer investment in the behavioral health practice management tech platforms and am re-posting that blog’s infographic.

Sources:

Alma: Optum

Alma: Cigna/Evernorth

Headway: HCSC

Octave Cigna/Evernorth

Rula Blue Venture Fund

January’s deductible season is in our near future. Which brings up a critical question: do clients with deductibles pay more if they see a clinician via a tech platform than they would in a private-practice setting?

Transfer pricing would appear to suggest that yes, clients pay more. Many clinicians openly state that the reason they join a tech platform is because the reimbursement rates are better than if they contracted directly. But do you really think that a tech platform pays 100% of the insurer’s allowed amount to the therapist? It’s doubtful. The venture capital which created the tech platforms is going to to want a return on their investments.

Clear Health Costs recently reported interviewing a therapist working for Alma who obtained Explanation of Benefits documentation from her clients. Alma paid her $79 for a 90834 with Cigna, but Alma received a $125 allowable amount. United’s reimbursement rate for an unspecified CPT code, probably 90837, was $142.80 to Alma, but the therapist was only paid $121.80. Imagine that; both Cigna and United are investors in Alma. Transfer pricing, hard at work.

That therapist’s Alma clients who have deductibles will be paying $142.80 and $125 per visit, not $121.80 or $79. Thereby making it more expensive per session to see a therapist via one of the tech platforms at least for clients with deductibles.

“But the platforms provide a service! There’s a mental health crisis and a behavioral health clinician shortage!”

“Access” is the stated mission of the tech platforms because everyone knows insurance companies don’t have adequate provider panels. But has the access problem been intentionally manufactured by insurance companies? I certainly can’t offer any proof of intention and no one could have predicted the universal adoption of telehealth as a result of the COVID pandemic. But I don’t think it’s unreasonable to conclude that stagnant reimbursement rates over decades, the ever-increasing complexity of administrative overload necessary for practices to get claims paid, audits, pre-payment reviews, clawbacks, and a months if not years-long credentialing/contracting process have all played a role in driving clinicians to say “Enough!” and leave the networks.

Clinicians entering private practice in the 2020’s are facing a daunting landscape of corporate behemoths. It’s easy to feel powerless and overwhelmed, afraid that you have no viable choice but to join the venture capital platforms if you’re to succeed professionally. It’s undeniable that the platforms do provide a means by which newly-licensed clinicians can enter into private practice more quickly even though this same arrangement clearly also benefits the insurers, who have less credentialing to do.

The choice among various private practice options is always yours, and you may have valid, understandable reasons for choosing to use a tech platform, even if only temporarily. Resources exist which can help you make an informed decision. If you decide to take an alternative path, one that might be harder at the start but more rewarding in the end, I can help with any private practice problem you might encounter.

URL: https://psychbillingcoach.com/tech-platform-money-trail/

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: November 16, 2025 at 11:36PM
SOURCE: PsychBilling Coach Billing Blog by Susan Frager
-------------------------------------------------

TITLE: 3 Paving Stones of the Tech Platform Money Trail

URL: https://psychbillingcoach.com/tech-platform-money-trail/

Yes, it’s true. Insurance companies are investors in Alma, Headway, Rula, etc. Worse, following the tech platform money trail back to its origins, we uncover the same economic dynamics in behavioral health that now control all of American healthcare. It’s disheartening, to say the least. Mental health parity in all the wrong ways!

Most of us think of the tech platforms as having emerged seemingly overnight in response to the mental health crisis and urgent need for services via telehealth brought on by COVID. But in reality, that’s not exactly correct. Both Alma and Headway began prior to COVID, in 2018-2019, which means the tech platform money trail stretches back further in time. As in the medical field, there are three concepts which, together, form the paving stones of this money trail.

• Medical Loss Ratio
•

• Vertical Integration
•

• Transfer Pricing
•

Medical Loss Ratio

In insurance-speak, the Medical Loss Ratio (MLR) is the percentage of premium dollars directly used to pay claims and for quality improvement/disease management expenditures. Money the insurance payer collects that isn’t used for these purposes goes to pay their operating costs. And, of course, profit. Wall Street expects a hefty profit on top, to please shareholders. That profit has to come from somewhere.

The government has attempted to ensure consumers and taxpayers are protected by defining the minimum percentage of premium dollars that must be spent directly on healthcare activities:

• ACA-regulated commercial & marketplace plans: 85% MLR is required for “large groups” and 80% for individual & small group plans. (note: states can choose to raise the MLR requirements).

• If you’ve ever received a random check from your insurer referencing a “medical loss ratio rebate,” it’s because your insurance company failed to meet the MLR target. They’re required by law to give back the corresponding percentage of your premiums they failed to spend on claims.
•

•

• Medicare “Advantage” requires an 85% or higher MLR.

• Plans with lower than 85% MLR must refund CMS.
•

• Contrast this with Original Medicare, where in 2021 the administrative costs (since there’s no profit requirement) hovered around 1.3% of Medicare’s budget.
•

•

• Medicaid Managed Care also requires the MLR to be at least 85%.
•

Vertical Integration

Vertical integration describes the acquisition by insurance companies of non-insurance healthcare entities. This can be anything from electronic clearinghouses such as Change Healthcare, to imaging, pharmacy benefit managers, specialty physician practices, ambulatory surgery centers, urgent care, and even consumer-facing information products such as Healthgrades, Medical News Today, and PsychCentral: all owned by RVO Health who’s owned by (you guessed it) United HealthGroup.

United is the most egregious vertical integrator, with 2,694 subsidiary companies. Everyone’s heard the statistic that United employs about 10% of American physicians, but the list of 2,694 subsidiaries demonstrates that behavioral health isn’t exempt. At least 75 large behavioral health practices are listed, including some with familiar names, such as Refresh Mental Health.

But United isn’t the only culprit. Availity, the portal most of us who deal with insurance claims must use (and love to hate), started in 2001 as a joint venture between Florida Blue and Humana. It was then acquired in 2006 by HCSC, owner of 5 Blue Cross/Blue Shield plans. Elevance/Anthem (14 BC/BS plans), and BCBS Minnesota joined as co-owners of Availity in 2009.

The list of Elevance’s (Anthem; Carelon) subsidiaries reveals that they own NGS Federal, LLC, otherwise known as National Government Services, the Medicare Administrative Contractor for 10 states, as well as infusion centers, a sales consultancy for healthcare startups, various Medicaid managed care organizations, even a legal services company focusing on healthcare cost containment (interesting side note: following this hyperlink will take you to a LinkedIn page. If you click on About, and then the company’s website, http://www.4600boehm.com/, you end up at Carelon Payment Integrity). Small world, eh?

Likewise, the Cigna Group has their own healthcare pyramid. Notable subsidiaries of Cigna include one of the largest American Pharmacy Benefit Managers, Express Scripts, which even has its own associated pharmaceutical distribution arm. EviCore, revealed last year by ProPublica to be the AI giant behind “medical necessity” prior authorization denials, is also owned by Cigna.

Transfer Pricing

So what’s to keep United from paying Refresh Behavioral Health’s clinicians more for a 90837 than they would pay you in an independent private practice? What’s to keep them from paying more for a surgery at one of their own ambulatory surgery centers than they would for the same surgery performed at an independent hospital?

Nothing! A study published this month in Health Affairs found that UHG-owned providers were paid anywhere from 17-61% more than those not owned by United.

The phenomenon of paying more for the same service to a company under the same corporate umbrella is known as transfer pricing. The money just moves from one side of the house to the other. But, that money is spent on claims so it nevertheless counts toward satisfying the government’s Medical Loss Ratio requirements.

As a result of vertical integration, transfer pricing has been the means by which the large insurer-owned conglomerates have gotten around the government’s well-intentioned Medical Loss Ratio requirements. The authors of the Health Affairs study concluded that even just a 1% price increase to wholly-owned subsidiaries could lead to billions of dollars “saved” from having to be rebated back to consumers or the federal government. And where does this money go, instead?

Corporate Profits, of course.

Paving the Tech Platform Money Trail

So, back to our behavioral health corner of the healthcare world. I previously reported on insurance payer investment in the behavioral health practice management tech platforms and am re-posting that blog’s infographic.

Sources:

Alma: Optum

Alma: Cigna/Evernorth

Headway: HCSC

Octave Cigna/Evernorth

Rula Blue Venture Fund

January’s deductible season is in our near future. Which brings up a critical question: do clients with deductibles pay more if they see a clinician via a tech platform than they would in a private-practice setting?

Transfer pricing would appear to suggest that yes, clients pay more. Many clinicians openly state that the reason they join a tech platform is because the reimbursement rates are better than if they contracted directly. But do you really think that a tech platform pays 100% of the insurer’s allowed amount to the therapist? It’s doubtful. The venture capital which created the tech platforms is going to to want a return on their investments.

Clear Health Costs recently reported interviewing a therapist working for Alma who obtained Explanation of Benefits documentation from her clients. Alma paid her $79 for a 90834 with Cigna, but Alma received a $125 allowable amount. United’s reimbursement rate for an unspecified CPT code, probably 90837, was $142.80 to Alma, but the therapist was only paid $121.80. Imagine that; both Cigna and United are investors in Alma. Transfer pricing, hard at work.

That therapist’s Alma clients who have deductibles will be paying $142.80 and $125 per visit, not $121.80 or $79. Thereby making it more expensive per session to see a therapist via one of the tech platforms at least for clients with deductibles.

“But the platforms provide a service! There’s a mental health crisis and a behavioral health clinician shortage!”

“Access” is the stated mission of the tech platforms because everyone knows insurance companies don’t have adequate provider panels. But has the access problem been intentionally manufactured by insurance companies? I certainly can’t offer any proof of intention and no one could have predicted the universal adoption of telehealth as a result of the COVID pandemic. But I don’t think it’s unreasonable to conclude that stagnant reimbursement rates over decades, the ever-increasing complexity of administrative overload necessary for practices to get claims paid, audits, pre-payment reviews, clawbacks, and a months if not years-long credentialing/contracting process have all played a role in driving clinicians to say “Enough!” and leave the networks.

Clinicians entering private practice in the 2020’s are facing a daunting landscape of corporate behemoths. It’s easy to feel powerless and overwhelmed, afraid that you have no viable choice but to join the venture capital platforms if you’re to succeed professionally. It’s undeniable that the platforms do provide a means by which newly-licensed clinicians can enter into private practice more quickly even though this same arrangement clearly also benefits the insurers, who have less credentialing to do.

The choice among various private practice options is always yours, and you may have valid, understandable reasons for choosing to use a tech platform, even if only temporarily. Resources exist which can help you make an informed decision. If you decide to take an alternative path, one that might be harder at the start but more rewarding in the end, I can help with any private practice problem you might encounter.

URL: https://psychbillingcoach.com/tech-platform-money-trail/

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