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What owners of therapy group practices search for at the end of a long week: missed first sessions, therapists who leave and the jobs that land on the owner, answered from the research.

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What to send when an insurer asks for therapy records, and what to keep back

HIPAA lets a practice send a payer the records it needs to decide payment without the client's authorization, limited to what the request needs. Psychotherapy notes are the exception. They need the client's specific authorization even for a payer, and a Medicare documentation request has 45 days on its clock.

45 daysto answer a Medicare contractor holding a claim for documentation

By Practice Pillar Editorial Staff

, a 5 minute read

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New clients

From the first call to the first session, and keeping the appointment.

2 posts

What to check about a client's insurance before the first therapy session

Before a first session, check that the plan is active on that date, which company manages its mental health benefit, that the clinician is in that company's network, what the client will pay and whether the plan limits visits or needs an authorization. A client who will not use insurance needs a Good Faith Estimate instead, on a clock that starts when the session is booked.

, a 7 minute read

A6the X12 code for psychotherapy, which a benefits check can ask about by name

Why new therapy clients miss their first session, and what helps

About a third of first appointments in outpatient mental health clinics go unattended. The wait before the first session is one part a group practice controls, and reminder texts help by a modest amount.

, a 4 minute read

34%of first appointments at outpatient mental health clinics went unattended

The team

Hiring, paying, supervising and keeping clinicians.

4 posts

Can a new therapist bill insurance before credentialing is done in Texas?

It depends on the payer. A Texas Medicaid managed care plan must treat a counselor, therapist, social worker or psychologist joining a contracted group as in network while it reviews them. Medicare lets a clinician bill up to 30 days before the effective date in some cases. Texas's expedited credentialing law for commercial plans covers physicians, podiatrists and therapeutic optometrists, not therapists.

, a 6 minute read

30 daysbefore the effective date, how far back Medicare lets a newly enrolled clinician bill

How long until a new therapist's caseload is full, and what sets the pace

A new therapist's caseload settles near the number of new clients they get each week times the number of weeks a client stays, and the last part of the climb takes longer than owners expect. For insured clients, the wait for each payer's credentialing comes first.

, a 5 minute read

19.7%of adult psychotherapy clients ended treatment early, across 669 studies

Paying W-2 therapists per session, and what federal wage law asks of a group practice

A W-2 therapist paid only by the session may not be exempt from overtime, because a per-session rate is usually not a salary. A guaranteed salary of at least $684 a week, with pay per session on top, is the structure the federal exemption is written around.

, a 7 minute read

$684a week is the lowest salary the federal overtime exemption for professionals allows

Why therapists leave group practices, and what keeps them

Therapists leave group practices over pay they cannot see and caseloads they were promised and did not get. One trial adds a finding owners rarely hear: staff stayed longer where monitoring was presented to them as support.

, a 4 minute read

81%mean staff turnover across 42 public mental health teams in one study

Running the practice

The owner's own week: the numbers to watch and the jobs to hand off.

2 posts

The numbers a therapy group practice should check every week, and how to read them

Ten counts, read every Monday, catch what an owner otherwise finds a month late: a caseload that stopped filling, a payer that slowed down, first sessions that keep getting missed. Each one needs its denominator, a blank week left blank and a comparison with the practice's own past rather than with anyone else's benchmark.

, a 5 minute read

4 weeksof the practice's own history, the only baseline each weekly count needs

Why the owner of a group practice ends up doing every job

Owners of therapy group practices describe the same problem in their own words: taxes, supervision and payroll on top of a caseload. It happens because the practice grew faster than its written ways of working, and it is undone one job at a time.

, a 3 minute read

53.6%of therapists and wellness practitioners named taxes as their top business challenge

Getting paid

Claims, denials, recoupments and what a payer owes the practice.

5 posts

Can a therapy practice charge for missed appointments? The rule for each kind of payer

Medicare lets a practice charge its patients for a missed appointment if the fee is the same for everyone. Texas Medicaid clients cannot be charged at all. Texas counselor rules allow a bill for an unkept appointment, and the fee has to be in the signed informed consent before the first session.

, a 5 minute read

$0what a Texas Medicaid client can be charged for a missed appointment

Can an LPC Associate bill insurance in Texas? Each payer answers differently

The Texas board lets an LPC Associate's sessions be billed when the billing documents show the license and the supervision. Each payer then decides whether it pays for them. Texas Medicaid's handbook says it will not, Medicare's rule runs through a supervising practitioner, and each commercial plan sets its own rule.

, a 5 minute read

60 daysto report and return an overpayment once it is identified, such as Medicaid paid for an associate

How to bill a therapy session held by video, and what changes by payer

A therapy session held by video is billed with the same CPT code as one held in the office. What changes is the place of service code and the modifier, and each payer sets those. Medicare wants POS 10 when the client is at home, Texas Medicaid wants modifier 95 for video and FQ for the phone, and Texas law makes fully insured plans cover a video session from an in-network clinician on the same basis as an office visit.

, a 7 minute read

6 monthsfor an office or video session before Texas Medicaid pays for one by phone

What to do when an insurer asks your therapy practice for money back

A PPO or HMO plan regulated by Texas has 180 days after it paid you to ask for money back, has to say why, and may not take the money while your appeal is open. Self-funded employer plans and Medicare follow other rules, so the first step is finding out which kind of plan sent the letter.

, a 7 minute read

180 daysfor a Texas-regulated plan to ask for money back after it paid you

Why therapy insurance claims get denied, and the denials a practice can stop before sending

Many reasons a payer gives for denying a therapy claim are facts the practice could have checked first, such as coverage that ended, a missing authorization, minutes that do not reach the code billed or a claim sent too late. Here is each one with the payer's own wording and the step that prevents it.

, a 7 minute read

95 daysto file a claim with a PPO or HMO that Texas regulates, or lose the right to be paid

Rules and records

Records requests, consent and the rules a practice answers to.

1 post

What to send when an insurer asks for therapy records, and what to keep back

HIPAA lets a practice send a payer the records it needs to decide payment without the client's authorization, limited to what the request needs. Psychotherapy notes are the exception. They need the client's specific authorization even for a payer, and a Medicare documentation request has 45 days on its clock.

, a 5 minute read

45 daysto answer a Medicare contractor holding a claim for documentation

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