DATE: May 7, 2026 at 03:25PM
SOURCE: PsychBilling Coach In the News by Susan Frager
-------------------------------------------------

TITLE: What’s this Medicare eligibility attestation demand?

URL: https://psychbillingcoach.com/news/medicare-eligibility-attestation/

Your clearinghouse may have been bugging you for the last month about a deadline on May 11, 2026, with respect to Medicare eligibility and something called HETS.  What the HECK is HETS? Will you get paid after Monday if you don’t get this done…whatever this is?

HETS stands for HIPAA Eligibility Transaction System, in other words the system Medicare uses when you inquire about the eligibility of an Original Medicare client.  I introduced HETS briefly last September when discussing “Death by 1,000 Cuts” –  a thousand onerous tasks continually placed onto clinicians by insurance payers or government Powers That Be.

Now, apparently, it’s 1,001.

What if I don’t make the May 11th deadline?

Good news: nothing terrible will happen if you don’t make Monday’s deadline.  You might be temporarily blocked from accessing Medicare eligibility via your EHR/clearinghouse connection, though, until you attest.

You will not be kicked off Medicare, and your claims will still be paid.

Does it apply to me?

If you’re enrolled to bill Original Medicare, then a HETS attestation is required if you’re going to be conducting eligibility inquiries via an EHR/clearinghouse connection.

Why is Medicare eligibility a good thing to have?

When accepting a Medicare client, I can’t think of anything more crucial than to verify their eligibility. And yet, mental health clinicians I consult with often don’t know this tool is available.

Medicare eligibility returns give you vital information:

• Date of eligibility for Medicare.
•
• Does the client have Part B? Not everyone enrolls in Part B at age 65.
•
• Date of last Coordination of Benefits update.
•
• Is Medicare the primary payer? If not, you’ll need the “MSP type code” for billing purposes and the eligibility inquiry will give that to you.
•
• Is the client enrolled in an “Advantage” or PACE plan?  If yes, the Medicare eligibility will tell you who the “Advantage” or PACE payer is.
•
• Is the client a Qualified Medicare Beneficiary (QMB)? You can’t collect any patient responsibility amounts (coinsurance or deductible) if your client is QMB-enrolled.
•
• Deductible status, for non-QMB clients.
•
• Is the client a Railroad Medicare beneficiary?
•
Can I get eligibility another way?

All Medicare Administrative Contractors (MACs) have online portals you can use to obtain eligibility. If you’re a portal user, the HETS attestation is contained within the registration process for the portal. At various intervals thereafter, the portal will make you re-attest before gaining eligibility information. So if you’re obtaining Medicare eligibility via a MAC portal rather than an EHR/clearinghouse, the May 11th deadline does not apply to you.

The only ways to obtain Medicare eligibility are via EHR/clearinghouse or MAC portal. CMS discontinued telephone eligibility inquiries as of March 31, 2025.

What are these rules of behavior?

One therapist I consulted with said it best: “Don’t be stupid.”

Click here to read the HETS Rules of Behavior, but it can be summarized in two words: Follow HIPAA!

There’s a bit more to it if you utilize an offshore individual or entity who has access to Medicare eligibility data.

Why is this such a big deal?

When a Medicare beneficiary’s ID number (MBI) is compromised, it can be used fraudulently. Identity theft and/or data breaches are common, and when this happens, CMS has to issue new MBI’s to all beneficiaries whose information was breached. Recently, this happened to about 1.3 million people with Medicare, who will now be receiving new ID numbers.

Wanna know how it happened? Apparently, it had something to do with Elon and DOGE. The story first broke in the Washington Post on April 30th. Here’s a link to the story, but there’s a subscriber-only paywall.

And the database DOGE apparently exposed, was a database of healthcare professionals! Which means not only was it your MBI which was disclosed, but also your social security number and, potentially other information about your practice which can be used to fraudulently submit Medicare claims under your provider number. If you think you might have been affected, click here to read what to do and how to protect yourself.

Tip for everyone: if a client’s Medicare claims all of a sudden deny stating that you used an invalid MBI, the first thing to do is ask your client if they were sent a new card. Clients may think that Medicare automatically updates you as to their new number but naturally, that would be too easy. Can’t have THAT!

Big Brother is watching…

From the Rules of Behavior:

“The Centers for Medicare & Medicaid Services (CMS) monitors inquiries in HETS, and we’ll contact you if we find discrepancies. For example, we’ll check if you submit a high ratio of eligibility inquiries compared to your Fee-for-Service (FFS) claims. If we suspect improper use or if you violate these rules of behavior, we may suspend you, place you on a corrective action plan, or refer you for investigation and you could be subject to other penalties, including civil or criminal actions.”

In other words, CMS will be using AI analytics to determine that a sufficient percentage of the Medicare eligibility inquiries you submit become actual claims for service to those beneficiaries.

What’s the “sufficient percentage?” No clue. CMS hasn’t shared that (to my knowledge). But my recommendation is that you not conduct any Medicare eligibility inquiries until a client has already scheduled an appointment. Don’t verify just based on a telephone inquiry from the client as to whether you can accept their insurance.

What if I do use an offshore vendor?

It’s not illegal, but it makes things more complex for you in terms of documenting compliance, both with the HETS Rules of Behavior and also HIPAA. And state law, if you happen to be located in Florida.

In general HIPAA terms, you as the “covered entity” are responsible for the conduct of your “business associate,” such as a biller or virtual assistant. Anyone who requires access to Protected Health Information (PHI) in order to carry out their job functions, is, by definition, a “business associate.”

If a business associate violates HIPAA, they can be held liable but you’re liable also! HIPAA mandates covered entities to carefully monitor their business associate’s compliance. Which is a lot harder to do if your business associate is located in a foreign country. And then there are legal considerations. Following US law may be the terms under which you engage this person or organization, but in reality, can there be any consequences to a foreign entity if something happens? That’s not a question I have adequate training to answer.

Making things even more snarled, some American billing / revenue cycle management entities employ offshore labor. So you might think you’re ok, not realizing that in fact there is offshoring going on. If you utilize a larger billing vendor, contact them to ask if any of their employees who view/utilize Medicare eligibility data are located outside the US and document their answer!

Getting back to your HETS attestation, CMS expects you to disclose any offshore arrangements in which foreign vendors/contractors view Medicare eligibility data and/or utilize HETS. If you have to answer “yes” to this question on the HETS attestation, I strongly recommend you utilize the services of a cybersecurity expert as well as a certified HIPAA auditor who can carefully investigate to ensure your compliance. If you utilize offshore help but obtain Medicare eligibility data via your MAC’s portal, I recommend the same actions. The HETS Rules of Behavior do apply to portal use; it’s only the attestation process which differs.

So how do I jump through this **** hoop?

By now, your EHR/clearinghouse should have sent you detailed instructions or else an alert may be on their website or when you log into your account.

This is the general workflow:

• Start by downloading your EHR/clearinghouse vendor’s instructions. You’ll need their “unique ID” in order to complete the attestation.
•
• Complete the CMS HETS Attestation via the process established by your MAC. You can find instructions for all MACs here.
•
• Notify your EHR/clearinghouse that you completed the attestation on [date].
•
• Your EHR/clearinghouse then does their part to ensure your access to HETS stays active, or is re-activated.
•

Simple Practice says they know nothing about this!

The Simple Practice EHR/clearinghouse doesn’t support Medicare eligibility transactions. If you’re a Simple Practice user, your only option for Medicare eligibility is the MAC portal, which means the May 11th deadline doesn’t apply to you.

Still running into trouble after following your clearinghouse’s instructions? You can schedule a short consultation here I’ve been churning out HETS attestations with clinicians for the last month or so!

It’s always SOMETHING, isn’t it?

URL: https://psychbillingcoach.com/news/medicare-eligibility-attestation/

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

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

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

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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

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

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DATE: April 28, 2026 at 07:16AM
SOURCE: PsychBilling Coach by Susan Frager
-------------------------------------------------

TITLE: Finding the value in value-based care

URL: https://psychbillingcoach.com/value-in-value-based-care/

If you’ve never heard about “value-based care,” it’s time to catch up, and fast! This July, Medicare will be premiering a 10-year pilot model called ACCESS: Advancing Chronic Care with Effective, Scalable Solutions.  While Medicare certainly has had other value-based innovations in the past, ACCESS is different because, for the first time, behavioral health is included.  

What is value-based care?

The short and sweet definition is when a payer (Medicare, Medicaid, or an insurance company) pays for population outcomes rather than procedures. While in theory that makes sense if you break your leg or have a heart attack, how realistic is this in practice for behavioral health?

Probably many of us would scoff, saying that it’s not. How do you measure outcomes in mental health at scale? And is a decreased score on the GAD or PHQ really indicative of a positive treatment outcome? (I’m not qualified to answer that question…)

Sure, practices can, and should, measure outcomes with their clients in whatever ways they feel are clinically appropriate. But unless you’re a huge group, you’re not measuring large numbers of clients. Nor is measuring outcomes the only definition of value-based care.

“Paying for outcomes” shows clearly that value-based care is also a financial arrangement. In private practice, you may reliably be demonstrating positive outcomes with your clients, but Medicare, BC/BS, etc., are still paying based on the CPT code billed. In other words, payment is based on claims that represent you as having delivered a session: 90837, 90834, 90847, etc.

The less short, and definitely not sweet, finances of value-based care

Value-based care involves financial capitation. Here’s how capitation works: the payer begins by determining a population to be covered. For example, let’s say that Aetna wants to contract with an entity to cover all behavioral health services for the 10,000 Aetna members living in a specific city.

Aetna decides how much they will pay per enrollee, or “per head” – hence the term “capitation,” which comes from the Latin term for “counting of heads.”  An easy way to remember capitation is to think about what “decapitate” means – to cut off someone’s head!

Gruesome joking aside, to continue with the example…

Aetna selects a provider entity who sub-contracts. In that contract, the provider entity agrees to provide all covered services to the members. Once done, Aetna simply pays the per-head (per-member) amount to the subcontractor/provider, and then washes their hands of responsibility thereafter to pay for care for any member in that group of 10,000 members. The subcontractor is now responsible for providing -and managing- all care.

Which places the subcontractor/provider financially at risk. Why? Because the more services are provided, the less profit they make. Their payment from Aetna is fixed. Aetna gets a great deal. The subcontractor/provider…who knows? Maybe it’s a great deal also. Maybe it’s not.

The clinical ethics of a value-based arrangement are usually enough to give most mental health professionals a sense of the “ickies.”

So capitation, the payment method for value-based care, requires scale. It isn’t going to be offered to even a group private practice, unless the group was seriously large (and probably financed by venture capital).

See where this is headed?

The Targets of ACCESS

Who provides mental health services at a scale large enough for a payer like Medicare to sit up, pay attention, and consider capitated reimbursement on the basis of outcomes rather than CPT codes?

Ah yes. Now we come to it. The platforms!

Sometimes morphed with, or looking like, national in-person or hybrid groups, because not all platforms hire clinicians as 1099’s. Then there’s a whole slew of AI, digital health, and apps.

Here’s a list of the platform entities which have signed up with Medicare as of April 23rd to participate in the behavioral health ACCESS program. (More may be forthcoming – Medicare’s deadline to sign up isn’t until May 15th).

• Headway

• Insurer investors: HCSC (BC/BS IL, MT, NM, OK, TX)
•

•

• Innerwell  (specializes in at-home ketamine tx, therapy platform)

• Venture capital, but no known insurer investment
•

•

• Isaac Health (specializes with dementia/caregivers)  

• Insurer investors: CareSource, Intermountain Healthcare
•

•

• SonderMind

• Insurer investors: Venture capital, but no known insurer investment
•

•

• Total Life 

• Insurer investor: GEHA
•

• Other investors of note: Google, Charm EHR
•

•

In Medicare’s own words, “The ACCESS Model will test whether an alternative payment methodology—Outcome-Aligned Payments (OAPs)—for technology-enabled chronic care reduces expenditures while preserving or enhancing quality of care for Medicare beneficiaries.”

Rules of ACCESS

For those who are interested in all the arcane details of ACCESS, Medicare’s 63-page description is here.

These are just a few highlights.

To participate in ACCESS, entities must enroll as an organization eligible to bill under Part B, have valid state licensure, comply with HIPAA, and appoint a Medicare-enrolled physician to act as Medical Director. (which nicely eliminates the platforms’ contention that they’re just billing/credentialing services!).

ACCESS will be available to both Original Medicare and Medicare-Medicaid dual-eligibles. Opting into a program under ACCESS will be the choice of the beneficiary, with no reduction in other Medicare services. Medicare beneficiaries enrolled in “Advantage” plans will not be allowed to participate. And, for any Medicare recipient who enrolls in an ACCESS track, the ACCESS organizational participant (Headway, etc) will be forbidden to receive fee-for-service Medicare part B payment for that individual during their 12 months of ACCESS enrollment.

The only qualifying behavioral health conditions for beneficiary enrollment in ACCESS are a diagnosis of either depressive and/or anxiety disorder. And the only “Outcome-Aligned Payment Measure” is listed as

• Control or minimum improvement in symptoms (assessed via PHQ-9 for depression and GAD-7 for anxiety)
•

Payment will be a fixed amount to ACCESS organizations, payable over a 12-month period, and the amount will be prorated up or down, depending on the reported outcomes.

Hmmmm….any potential for fraud here?

The idea is apparently for the ACCESS participant organizations to utilize some form of technology to achieve the goals. These are some of the listed AI/app technologies that have signed up to participate in ACCESS:

• Altitude Cares Inc  their website proudly trumpets that it was built by leaders from CVS, Devoted Health, and Optum (is this a GOOD thing?!?)
•

• Ciba Health
•

• Headspace
•

• Limbic Care, PC 
•

• M3 Information. An AI tool for primary care providers to asses mental health conditions
•

• Meomind AI    RECORDED ACTUAL SESSIONS TO LISTEN TO, via an app. Plus live chat. Seems like a sort of BetterHelp model. Their website claims that clients gave consent for their therapy sessions to be recorded and published.
•

• Mindset Health
•

• MyHealthTrack   
•

• NeuroTap Health, Inc
•

• Slingshot AI  -the Ash therapy chatbot
•

In the fall of 2024, it was reported by Behavioral Health Business that Headway, in conjunction with the National Quality Forum, has been engaged in an initiative called Aligned Innovation, to develop a patient self-reporting outcomes tool that, in theory, will one day replace all others, and become the standard of care – whether insurance is paying for care or not.

““Measures will become broadly adopted and used, not just by one payer saying that they want to use them…, but when multiple payers in a market all align and say, ‘We’re going to all hold you, providers in our network, accountable for this measure, and we’re all going to use the same measure and do it in the same way,”’ Dana Gelb Safran, president and CEO of NQF, told BHB.

I’m not making a clinical argument about the necessity for measurement of outcomes, which is important. But when entities with a financial stake control both the development of the outcome measure and then leverage their power to mandate its use, which in turn determines how much and what type of treatment they’ll cover, I smell a serious conflict of interest, if not outright abuse of power.

And what’s disheartening is that CMS, for all the recent exclamations in the news about stamping out fraud, seems as if they might be opening up Medicare to fraud in newer areas.

Time will tell. But even if no fraud results, I do have to wonder about where this leaves solo behavioral health clinicians and smaller groups. If fee for service payment is ultimately discarded in favor of value-based care, what happens to the clinician who can’t or doesn’t want to scale? I seem to recall from my graduate statistics classes that small sample sizes aren’t valid for determining conclusions – which means value-based care could never be offered to independent clinicians. Is this a signpost on the road to extinction, if the dominant method of payment for healthcare becomes value-based??

That’s only one question. It seems to me that another major potential flaw concerns co-occurring diagnoses, severe histories of trauma, and lack of client privilege/history of marginalization (whether racial, economic, occupational/educational, ability/disability, other social determinants of health, religious background, gender, LGBTQ+, employment, etc). Clients with any of these characteristics might predispose ACCESS organizations to subtly discourage their enrollment into the value-based ACCESS program. Enough “severe” clients – there go your stats, and whoops! Your money too…

All in all, it seems to me that Medicare’s ACCESS, while well-intentioned, raises a lot of unanswered questions, at least as it pertains to behavioral health.

URL: https://psychbillingcoach.com/value-in-value-based-care/

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: April 28, 2026 at 07:16AM
SOURCE: PsychBilling Coach Billing Blog by Susan Frager
-------------------------------------------------

TITLE: Finding the value in value-based care

URL: https://psychbillingcoach.com/value-in-value-based-care/

If you’ve never heard about “value-based care,” it’s time to catch up, and fast! This July, Medicare will be premiering a 10-year pilot model called ACCESS: Advancing Chronic Care with Effective, Scalable Solutions.  While Medicare certainly has had other value-based innovations in the past, ACCESS is different because, for the first time, behavioral health is included.  

What is value-based care?

The short and sweet definition is when a payer (Medicare, Medicaid, or an insurance company) pays for population outcomes rather than procedures. While in theory that makes sense if you break your leg or have a heart attack, how realistic is this in practice for behavioral health?

Probably many of us would scoff, saying that it’s not. How do you measure outcomes in mental health at scale? And is a decreased score on the GAD or PHQ really indicative of a positive treatment outcome? (I’m not qualified to answer that question…)

Sure, practices can, and should, measure outcomes with their clients in whatever ways they feel are clinically appropriate. But unless you’re a huge group, you’re not measuring large numbers of clients. Nor is measuring outcomes the only definition of value-based care.

“Paying for outcomes” shows clearly that value-based care is also a financial arrangement. In private practice, you may reliably be demonstrating positive outcomes with your clients, but Medicare, BC/BS, etc., are still paying based on the CPT code billed. In other words, payment is based on claims that represent you as having delivered a session: 90837, 90834, 90847, etc.

The less short, and definitely not sweet, finances of value-based care

Value-based care involves financial capitation. Here’s how capitation works: the payer begins by determining a population to be covered. For example, let’s say that Aetna wants to contract with an entity to cover all behavioral health services for the 10,000 Aetna members living in a specific city.

Aetna decides how much they will pay per enrollee, or “per head” – hence the term “capitation,” which comes from the Latin term for “counting of heads.”  An easy way to remember capitation is to think about what “decapitate” means – to cut off someone’s head!

Gruesome joking aside, to continue with the example…

Aetna selects a provider entity who sub-contracts. In that contract, the provider entity agrees to provide all covered services to the members. Once done, Aetna simply pays the per-head (per-member) amount to the subcontractor/provider, and then washes their hands of responsibility thereafter to pay for care for any member in that group of 10,000 members. The subcontractor is now responsible for providing -and managing- all care.

Which places the subcontractor/provider financially at risk. Why? Because the more services are provided, the less profit they make. Their payment from Aetna is fixed. Aetna gets a great deal. The subcontractor/provider…who knows? Maybe it’s a great deal also. Maybe it’s not.

The clinical ethics of a value-based arrangement are usually enough to give most mental health professionals a sense of the “ickies.”

So capitation, the payment method for value-based care, requires scale. It isn’t going to be offered to even a group private practice, unless the group was seriously large (and probably financed by venture capital).

See where this is headed?

The Targets of ACCESS

Who provides mental health services at a scale large enough for a payer like Medicare to sit up, pay attention, and consider capitated reimbursement on the basis of outcomes rather than CPT codes?

Ah yes. Now we come to it. The platforms!

Sometimes morphed with, or looking like, national in-person or hybrid groups, because not all platforms hire clinicians as 1099’s. Then there’s a whole slew of AI, digital health, and apps.

Here’s a list of the platform entities which have signed up with Medicare as of April 23rd to participate in the behavioral health ACCESS program. (More may be forthcoming – Medicare’s deadline to sign up isn’t until May 15th).

• Headway

• Insurer investors: HCSC (BC/BS IL, MT, NM, OK, TX)
•

•

• Innerwell  (specializes in at-home ketamine tx, therapy platform)

• Venture capital, but no known insurer investment
•

•

• Isaac Health (specializes with dementia/caregivers)  

• Insurer investors: CareSource, Intermountain Healthcare
•

•

• SonderMind

• Insurer investors: Venture capital, but no known insurer investment
•

•

• Total Life 

• Insurer investor: GEHA
•

• Other investors of note: Google, Charm EHR
•

•

In Medicare’s own words, “The ACCESS Model will test whether an alternative payment methodology—Outcome-Aligned Payments (OAPs)—for technology-enabled chronic care reduces expenditures while preserving or enhancing quality of care for Medicare beneficiaries.”

Rules of ACCESS

For those who are interested in all the arcane details of ACCESS, Medicare’s 63-page description is here.

These are just a few highlights.

To participate in ACCESS, entities must enroll as an organization eligible to bill under Part B, have valid state licensure, comply with HIPAA, and appoint a Medicare-enrolled physician to act as Medical Director. (which nicely eliminates the platforms’ contention that they’re just billing/credentialing services!).

ACCESS will be available to both Original Medicare and Medicare-Medicaid dual-eligibles. Opting into a program under ACCESS will be the choice of the beneficiary, with no reduction in other Medicare services. Medicare beneficiaries enrolled in “Advantage” plans will not be allowed to participate. And, for any Medicare recipient who enrolls in an ACCESS track, the ACCESS organizational participant (Headway, etc) will be forbidden to receive fee-for-service Medicare part B payment for that individual during their 12 months of ACCESS enrollment.

The only qualifying behavioral health conditions for beneficiary enrollment in ACCESS are a diagnosis of either depressive and/or anxiety disorder. And the only “Outcome-Aligned Payment Measure” is listed as

• Control or minimum improvement in symptoms (assessed via PHQ-9 for depression and GAD-7 for anxiety)
•

Payment will be a fixed amount to ACCESS organizations, payable over a 12-month period, and the amount will be prorated up or down, depending on the reported outcomes.

Hmmmm….any potential for fraud here?

The idea is apparently for the ACCESS participant organizations to utilize some form of technology to achieve the goals. These are some of the listed AI/app technologies that have signed up to participate in ACCESS:

• Altitude Cares Inc  their website proudly trumpets that it was built by leaders from CVS, Devoted Health, and Optum (is this a GOOD thing?!?)
•

• Ciba Health
•

• Headspace
•

• Limbic Care, PC 
•

• M3 Information. An AI tool for primary care providers to asses mental health conditions
•

• Meomind AI    RECORDED ACTUAL SESSIONS TO LISTEN TO, via an app. Plus live chat. Seems like a sort of BetterHelp model. Their website claims that clients gave consent for their therapy sessions to be recorded and published.
•

• Mindset Health
•

• MyHealthTrack   
•

• NeuroTap Health, Inc
•

• Slingshot AI  -the Ash therapy chatbot
•

In the fall of 2024, it was reported by Behavioral Health Business that Headway, in conjunction with the National Quality Forum, has been engaged in an initiative called Aligned Innovation, to develop a patient self-reporting outcomes tool that, in theory, will one day replace all others, and become the standard of care – whether insurance is paying for care or not.

““Measures will become broadly adopted and used, not just by one payer saying that they want to use them…, but when multiple payers in a market all align and say, ‘We’re going to all hold you, providers in our network, accountable for this measure, and we’re all going to use the same measure and do it in the same way,”’ Dana Gelb Safran, president and CEO of NQF, told BHB.

I’m not making a clinical argument about the necessity for measurement of outcomes, which is important. But when entities with a financial stake control both the development of the outcome measure and then leverage their power to mandate its use, which in turn determines how much and what type of treatment they’ll cover, I smell a serious conflict of interest, if not outright abuse of power.

And what’s disheartening is that CMS, for all the recent exclamations in the news about stamping out fraud, seems as if they might be opening up Medicare to fraud in newer areas.

Time will tell. But even if no fraud results, I do have to wonder about where this leaves solo behavioral health clinicians and smaller groups. If fee for service payment is ultimately discarded in favor of value-based care, what happens to the clinician who can’t or doesn’t want to scale? I seem to recall from my graduate statistics classes that small sample sizes aren’t valid for determining conclusions – which means value-based care could never be offered to independent clinicians. Is this a signpost on the road to extinction, if the dominant method of payment for healthcare becomes value-based??

That’s only one question. It seems to me that another major potential flaw concerns co-occurring diagnoses, severe histories of trauma, and lack of client privilege/history of marginalization (whether racial, economic, occupational/educational, ability/disability, other social determinants of health, religious background, gender, LGBTQ+, employment, etc). Clients with any of these characteristics might predispose ACCESS organizations to subtly discourage their enrollment into the value-based ACCESS program. Enough “severe” clients – there go your stats, and whoops! Your money too…

All in all, it seems to me that Medicare’s ACCESS, while well-intentioned, raises a lot of unanswered questions, at least as it pertains to behavioral health.

URL: https://psychbillingcoach.com/value-in-value-based-care/

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 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

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

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

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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