5 of the best cognitive behavioral therapy books
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Learn more about clawbacks and how you can prevent them.
Getting paid for your work as a mental health provider can be an involved process if you accept insurance. After seeing a client for a therapy session, you bill the insurance payer with a claim that includes specific CPT codes. Eventually — hopefully, quickly! — the insurance company reimburses you for the negotiated rate.
In an ideal world, you’d get to keep that money, no questions asked. But in rare cases, insurance companies “claw back,” or rescind the reimbursement they’ve paid out to a provider. Fortunately, there are some steps you can take to reduce the likelihood of a clawback affecting your practice’s budget.
Below, learn more about clawbacks, how you can help prevent them, and how Headway can help.
In the insurance realm, a clawback happens when an insurance company takes money it’s already paid for a service back from a provider. This can happen when the payer conducts a random audit, or if the payer notices red flag behaviors in documentation, such as billing higher-paying codes too frequently.
“If the payer thinks the service you provided doesn’t meet the code or meet medical necessity, then they might determine you owe them money back,” explains Michael Heckendorn, Headway’s clinical lead of clinician education.
In rare cases, providers may knowingly upcode — say, billing for an hour therapy session when they only saw the client for 45 minutes. Clawbacks can also occur if a client doesn’t disclose to you that they no longer have the same insurance plan (like in the event of a job loss).
More commonly, though, insurance companies claw back when providers don’t (or can’t) justify medical necessity in their documentation. For example, if you see a client every week for a full hour even when their symptoms improve, your insurance payer may determine shorter sessions are more appropriate and then collect the difference.
The great news is that these recoupment circumstances are avoidable. To ensure this, keep a few things in mind:
In most cases, Headway will reach out to you directly if there’s a complication or question about the way something is submitted. We’ll do our best to avoid surprising you or editing your payments, and make an effort to work with you in advance if this comes up.
If you’re confident in the compliance of your documentation and the medical necessity of your practice, then you typically shouldn’t need to worry about clawbacks. “As long as you practice honesty, your clients are in need of care, and you’re documenting and billing appropriately, that money should be guaranteed to you, and you shouldn’t have to justify it after getting reimbursed,” says Heckendorn.
To that end: If you do experience a clawback, you can take steps to dispute it with the insurance payer. The process is different for every insurance company, so your best bet is to reach out to the payer and find out what you can do to justify your work (and hopefully avoid losing money).
Ensuring documentation compliance and dealing with insurers on your own can be both time-consuming and stressful. When you’re a Headway provider, we’ve got your back. In addition to simplifying the insurance process and promising consistent payments every two weeks, we’ll protect you from clawbacks — even if a claim is denied, a charge is disputed, or a patient doesn't pay after a session. So when you get paid, you stay paid.
Ultimately, Headway views clawbacks as a last resort. As your practice partner, our goal is to work collaboratively to resolve any concerns that arise. When we don’t receive communication from providers, we can’t properly communicate with insurers. In the event that a provider’s lack of communication makes it difficult to understand the services provided, we may have to return the payment to the insurer and will adjust the provider's payments to reflect this. In the rare event that we have to adjust a provider's payment, we will communicate directly with the provider. Headway works collaboratively with both providers and insurers, meaning you can rest assured your hard and important work as a mental health provider will pay off.
Add these CBT books to your shelf to support your clients on their mental health journeys.
Wiley PracticePlanners help mental health clinicians better treat their clients by providing customizable, evidence-based treatment goals, objectives, and interventions.
It’s key to broach the subject up front so there are no surprises later on.