Posted by Kym Tolson, LCSW, CSAC, Traveling Therapist and Boss Biller
One of the things that frightens therapists the most about billing for more money is the idea that they might make mistakes that could be construed as fraudulent. Or even, unknowingly, use a mental health billing practice they thought was okay but turned out to be illegal!
Anxiety about this can be so worrisome that it keeps therapists, just like you, from collecting fees they rightfully deserve. So how can you avoid illegality and enjoy well-deserved prosperity?
Knowledge is the power you need. Learn below what not to do so that you’ll bill for more money the right way. Essentially, it comes down to avoiding two common, but problematic, practices: balance billing and upcoding.
This type of accounting occurs when a therapist bills their in-network client for the difference between the cost of services and the amount that their insurance company pays in benefits. This can occur with some frequency because the funds that insurance companies pay therapists are usually less than the therapist's stated charge. Attempts to make up the difference, or balance, through a bill to the client is thus called “balance billing.”
It should also be noted that it is illegal to balance bill your in-network clients as well. When you contract with insurers, you consent to accept the companies’ payments in full. Outside of any copay, deductible, or coinsurance, billing, the client further is off-limits.
This practice of applying higher codes for more money when they really don’t apply is viewed as dishonest. Essentially, it’s a kind of false claim. At best it is frowned upon; at worst, it’s fraud. More specifically, “upcoding” occurs when a therapist employs billing codes that indicate a more grave or serious disorder or diagnosis than exists. This also occurs when therapists indicate that more complex, and time-consuming, and expensive approaches or therapy were used than was actually afforded to their clients.
Upcoding happens for a couple of reasons, though neither legitimates doing it:
1. Therapists do it to obtain inflated reimbursements. Misleading “current procedural technology” (CPT) codes can be profitable in the short term, but make no mistake that it is an illegal violation of the False Claims Act (FCA)
All therapists are aware and agree to certain ethical standards in this regard. Ensuring accuracy in billing and payments so that you are totally compliant with the law is the safest course. Any other isn’t worth the headache or paranoia.
Avoid trouble by using the correct codes and billing with integrity.
2. Some therapists do it thinking they are doing their clients a favor. Upcoding could definitely afford some patients who could afford care services without harming their income. Unfortunately, this doesn’t count the cost to the therapist-client relationship, which is built on trust. In addition to jeopardizing your practice, your willing dishonesty may inadvertently harm or corrupt the connection you’ve built.
When it comes to billing codes, it’s always best to be as accurate as possible. Maintain your personal and professional standards; there are plenty of tools you can use legally to support your bottom line. The key is to find and follow the guidance of experts who can help you.
With the billing “don’ts” explained, you can see that your billing “dos” are rooted in knowing the correct information and letting your good character lead you. In addition, some support from a billing expert who will champion your efforts to build your profits can hurt either. That’s exactly why I’m here. Even better, I offer a product that thoroughly explains upcoding correctly to use the right codes. (https://insurance-billers-online-therapy.teachable.com/p/billing-for-more-money/?preview=logged_out) It can help honestly boost your billing IQ as well as your confidence.