Author Topic: Billing for lcsw  (Read 1576 times)

Healthy

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Billing for lcsw
« on: April 05, 2013, 04:07:55 PM »
Hi all,
I have a question if any one can help me, I am very confused.
I do billing for mental health,provider has hired a lcsw and she is credential with some insurances but not with Cigna and united health care because both are not taking any more lcsw on their panels.
Question is that lcsw does see Cigna members and MD supervise her,can I bill lcsw services under MD as supervising physician? And if yes how? Do I have to use NPI for MD as supervising and rendering provider as lcsw and billing provider NPI for group? And do I have to use any modifier?
Please answer me in detail.
Thanks to all.

RichardP

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Re: Billing for lcsw
« Reply #1 on: April 05, 2013, 04:38:24 PM »
Healthy, you said:  provider has hired a lcsw ...

You have an employer / employee situation here, so the information at the following link applies.  The post is talking about Medicare, but the info is relevant to commercial carriers also.  You can bill for the work of the lcsw using the provider's NPI number.  The link tells you how.

http://www.medicalbillinglive.com/members/index.php?topic=7045.msg21031#msg21031

Healthy

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Re: Billing for lcsw
« Reply #2 on: April 05, 2013, 05:10:21 PM »
My mistake. Actually she is not on salary. She gets paid per patient but we use group NPI for billing.
All of therapists are licensed and have their own NPI and all NPI are linked to group NPI.

RichardP

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Re: Billing for lcsw
« Reply #3 on: April 05, 2013, 10:54:50 PM »
Health, you said:  She gets paid per patient ...  Who pays her?  Your Group?  Or the insurance carrier?  The answer to who pays her? will determine what my answer to you should be.

It sounds like you are discussing a Group practice, and the legal entity that is the Group has a Group NPI.  It sounds like any billing would require the Group NPI (Type 2 - who gets paid) and the individual practitioner NPI (Type 1 - who did the work).  I am assuming this is the case in your situation, so here are a few points to consider, based on my assumption.

If this collection of workers meets the CMS definition of "Group", then payment may not be sent to any individual practitioner within the Group for work done under the name of the Group.  Payment must be sent to the legal entity that is your Group name.  Payment for the charges goes to the Group, and the Group pays the individual practitioners / subcontractors for work done under the name of the Group.  (Note that, if the Group allows a practitioner to work outside of the Group name, this restriction is not in force for that work done outside of the Group.)

Also, for a collection of workers who meet the CMS definition of "Group",  no individual practitioner within the Group may be a participating provider in an insurance carrier plan - while working for, and being paid by, the Group.  Rather, the participating provider would be the legal entity that is your Group name.  (Note that, if the Group allows a practitioner to work outside of the Group name, this restriction is not in force for that work done outside of the Group.)

A nurse practitioner, and maybe a lcsw, can do business in their own name, just like a doctor (assuming certain conditions are met).  In this situation, the Type 1 NPI (who did the work) and the Type 2 NPI (who gets paid) on the billing document would both belong to the nurse pratitioner or lcsw.  I know that at least the nurse practitioner will get paid less if s/he bills in her own name this way.  Which leads at least the nurse practioner to often bill under her employer's Type 2 NPI (who gets paid), while providing her Type 1 NPI (who did the work).  Her employer gets paid at the higer rate, and turns around and pays her.  The amount the employer pays her is up to the employer.

In your situation, it sounds like the employer of the lcsw is the Group.  If your setup meets the CMS definition of "Group", then your Group is the participating provider in CIGNA and United Health Care - not the individual practitioners.  Your lcsw would do the work, and a bill would be submitted to either CIGNA or UHC with the Group's Type 2 NPI (who gets paid) and the lcsw's Type 1 NPI (who did the work).  Because the charges are being billed in the name of the Group, and the insurance carriers would recognize that the Group is a participating provider, the charges would be paid at the contracted rate.  This is the required configuration for billing unless your lcsw is authorized to bill under her own name.  But, if your lcsw is being paid for her work by your group, she is not allowed to bill under her own name even if she is authorized to.  Billing under her own name would cause payment to go directly to her, and not to your Group.  And if your Group is paying the lcsw for her work ... and she gets the money from the insurance carrier instead of your Group getting it ...

The fact that your lcsw is not credentialed with CIGNA or UHC would be an issue only if she were billing under her own name.  Since she is being paid for her work by the Group, she should bill in the Group's name, not her own.

PMRNC

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Re: Billing for lcsw
« Reply #4 on: April 06, 2013, 09:02:59 AM »
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In your situation, it sounds like the employer of the lcsw is the Group.  If your setup meets the CMS definition of "Group", then your Group is the participating provider in CIGNA and United Health Care - not the individual practitioners. 

That is true however the carriers do require each joining group member to be included in the credentialing. If a group adds a provider to the group they have to notify the carrier, whether the network is closed or not. They have to submit all the paperwork as with the other providers.

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Your lcsw would do the work, and a bill would be submitted to either CIGNA or UHC with the Group's Type 2 NPI (who gets paid) and the lcsw's Type 1 NPI (who did the work).  Because the charges are being billed in the name of the Group, and the insurance carriers would recognize that the Group is a participating provider, the charges would be paid at the contracted rate.  This is the required configuration for billing unless your lcsw is authorized to bill under her own name.  But, if your lcsw is being paid for her work by your group, she is not allowed to bill under her own name even if she is authorized to.  Billing under her own name would cause payment to go directly to her, and not to your Group.  And if your Group is paying the lcsw for her work ... and she gets the money from the insurance carrier instead of your Group getting it .

Again, true but again, the provider HAS to be credentialed With the group, otherwise the carrier would not have any clue as to the credentials of the provider, Cigna and UHC also have TPA's for most of their plans for mental health. For example UHC uses UBH and all providers have to be credentialed within the group. cigna has a few different TPA's but they all work the same way. EACH provider within the group is required to be credentialed within the group.

Just as as side note, closed networks don't always mean you can't join, if your provider/group is within a geographical location where they provide services and don't have other providers within a certain distance they can credential on an exception. Mental health providers are scarce so the closed network status should NOT be a problem because again those major carriers use TPA's and you would credential with them.  For example if BCBS had closed network, a mental health provider can still credential with Magellan Behavior Health. I've never had a problem with closed networks and my mental health providers.

When I run into situations like this I don't try to figure out the legal structure of the group as that's outside my scope so I have the group consult with their attorney.  I've run into situations where I was told a provider was now a part of a group and then had carrier come back and not cover because the provider wasn't credentialed with the group. Your still disclosing the rendering provider on the claims.. OR you should be anyway.
Linda Walker
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RichardP

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Re: Billing for lcsw
« Reply #5 on: April 06, 2013, 11:27:21 AM »
Linda, I don't know mental health, so I cannot provide any detailed answers in that area.  Healthy sounds like s/he is new to all of this so I gave a general framework that s/he can respond to.  Based on that response, we can further refine our responses.  Don't want to overwhelm Healthy with all of the permutations that are possible.

It isn't clear to me whether Healthy's "Group" meets the CMS definition of Group.  If it doesn't, the requirements are different from what they are for a CMS-defined Group.  Further, it is not clear whether Healthy's lcsw is intended to be a member of the Group, or simply an employee or subcontractor of the Group, regardless of whether it is CMS-defined.  From the link I provided in my initial response, you can see that a CMS-defined Group can have employees and subcontractors.  These employees and subcontractors would not be members of the Group, and so credentialing requirements would be different than for members of the Group.

For a collection of workers to meet the CMS definition of "Group", the pay of Group members must be set by formula.  Payment cannot in any way be directly tied to productivity.  Since Healthy's lcsw is being paid per patient, that is a direct link between productivity and pay.  Therefore, the lcsw cannot legally be a member of the Group.  S/he must be either an employee or subcontractor.

Your statement about credentialing requirements are correct for members of a CMS-defined group, where the legal entity of the Group name is who gets paid from the carriers.  (And as you said, the carriers must have a list of all members who belong to the Group; new members must be added to that list before the carrier will pay the Group for the new member's work.)  But, so far as I understand it, those credentialing requirements do not extend to employees or subcontractors of the Group.  As I stated above - if a Nurse Practitioner is authorized to bill in their own name, they can - but they will be paid less than if they bill in the name of their employer.  Two situations:  if they bill in their own name, the Type 2 (who gets paid) and Type 1 (who did the work) NPI numbers must belong to the Nurse Practitioner.  Payment goes directly to the NP, but at a reduced rate; if they bill in the name of their employer, the Type 2 (who gets paid) NPI number must be that of their employer, and the Type 1 (who did the work) NPI number must be their own.  I know this setup applies to Nurse Practitioners.  I do not know if it also applies to Healthy's lcsw.

Healthy needs to come back with some more-specific information before we can begin to know how to tailor our responses.  If Healthy is new to this, s/he may not know what that specific information is.  That is why I began the narrowing-down process by asking who pays the lcsw.  That will hint at whether the lcsw is a member of the Group, or an employee or subcontractor.  Since the lcsw is being paid per patient, I'm guessing s/he is an employee or subcontractor.  If s/he is a member of the Group, then the Group is violating the requirements that must be met in order to be considered a CMS-defined Group.

Healthy

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Re: Billing for lcsw
« Reply #6 on: April 06, 2013, 11:52:38 AM »
Ok. Yes I am very new to this field , here is my case.
Doctor was solo practioner and has a group NPI and has proffesional corporation(PC).
Recently he start hiring APRN and LCSW and LPC's. all of them work part time for fee for service, they get paid by Doctor according to agreement they made. When they see patient they get paid for that.
No other benefits are provided to them as they work few evenings.
I am not sure about credentialing process, how it is set up at carrier level.
All I know is that they are credential with some carriers and rest like Cigna and UHC has closed their network for LPC's and LCSW's in my area.
I am billing for their services under group NPI and use their NPI as rendering provider, no modifier is used and no supervising physician's NPI is used.
Now my concern is that how I can bill their services to the carrier who have closed their network for them?
I hope this will clear my case and I will get right advice.
If still its not clear , please let me know.
Thanks

Healthy

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Re: Billing for lcsw
« Reply #7 on: April 07, 2013, 08:13:20 AM »
Please answer me.

PMRNC

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Re: Billing for lcsw
« Reply #8 on: April 07, 2013, 11:17:50 AM »
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Your statement about credentialing requirements are correct for members of a CMS-defined group, where the legal entity of the Group name is who gets paid from the carriers.  (And as you said, the carriers must have a list of all members who belong to the Group; new members must be added to that list before the carrier will pay the Group for the new member's work.)  But, so far as I understand it, those credentialing requirements do not extend to employees or subcontractors of the Group.  As I stated above - if a Nurse Practitioner is authorized to bill in their own name, they can - but they will be paid less than if they bill in the name of their employer.  Two situations:  if they bill in their own name, the Type 2 (who gets paid) and Type 1 (who did the work) NPI numbers must belong to the Nurse Practitioner.  Payment goes directly to the NP, but at a reduced rate; if they bill in the name of their employer, the Type 2 (who gets paid) NPI number must be that of their employer, and the Type 1 (who did the work) NPI number must be their own.  I know this setup applies to Nurse Practitioners.  I do not know if it also applies to Healthy's lcsw.

Although I agree that CMS guidelines are similar with other carriers, it is MOOT with mental health because of the TPA's used. Her original post mentioned two commercial carriers that both use TPA's.. up to 4 or 5 of them with the carriers she mentioned depending on the PLAN.  The CMS guidelines of a GROUP isn't the only condition and because she was clear this was a mental health provider I don't think it accurate to just give her the CMS guidelines and also my final statement was that this was a legal entity situation that an attorney for the provider should be resolving, it's not up to a medical billing to define a legal entity.


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Doctor was solo practioner and has a group NPI and has proffesional corporation(PC).
Recently he start hiring APRN and LCSW and LPC's. all of them work part time for fee for service, they get paid by Doctor according to agreement they made. When they see patient they get paid for that.
No other benefits are provided to them as they work few evenings.
I am not sure about credentialing process, how it is set up at carrier level.
All I know is that they are credential with some carriers and rest like Cigna and UHC has closed their network for LPC's and LCSW's in my area.
I am billing for their services under group NPI and use their NPI as rendering provider, no modifier is used and no supervising physician's NPI is used.
Now my concern is that how I can bill their services to the carrier who have closed their network for them?
I hope this will clear my case and I will get right advice.
If still its not clear , please let me know.

I'm not FULLY comfortable giving a legal definition as I can only go by what I know and while Richard gave you CMS guidelines they are indeed differen where mental health is concerned in credentialing with group health plans. IF this will be a true "GROUP" and the GROUP is credentialed with a carrier that is claiming they are now closed, they SHOULD be able to ADD the provider according to the scope of their license and state you are in to the GROUP contract. But again, remember that if they are in network with Aetna they may NOT be in network with the TPA's that handle the mental health claims for managed care plans. So while credentialing with Aetna is fine, there may be Aetna plans that use TPA's you may not be in network with. From my own knowledge in the states I work in I can name at least 3 major TPA's that Aetna uses, and again it depends on the plan. The same goes for BCBS, they too use TPA's, their biggest being Magellan Behavioral.   Now I know that was not your question but I did want to make sure you had a clear understanding in credentialing with carriers that have TPA's to process mental health plan. Those TPA's have their own method of credentialing. IF your provider has a contract with the carrier OR TPA, then you can indeed add a provider according to their scope of license/credentials to an existing contract, EVEN if the network is closed because the group is already contracted, you merely just need to add the provider to the credentialing process. What I do is make it really simple for myself and CALL the carrier/TPA of that plan and ask THEM how they want you to do it. I've seen small TPA's merely only need a name, license number and copy of current license and they will retroactively put them on the contract as of the day they started with the group (FOR existing network contracted providers)  IF The group is NOT credentialed with a closed panel, all is not automatically lost. I dig a bit deeper to find out how and IF it's possible I can get my client onto a closed panel, that does indeed get a bit more involved but it's not impossible all of the time. The carrier will usually give you criteria to appeal a closed network as they have criteria they use to go around the closed panel. For example I had a provider that provided biofeedback and was able to credential with a carrier that was a closed network because he was the only one within 100 miles providing Biofeedback (JUST an example).  I also took note that your group had a physician in it and you stated that the carriers you mentioned were closed to LCSW's, but again that is normally for NEW provider's and your group is already credentialed. Also you only mentioned the commercial carriers and again, not the TPA's which do require separate credentialing.   Now it is quite possible since your provider was a psychiatrist that he only credentialed with the major medical carriers and NOT the TPA's because of his credentials as a physician they didn't question it and it wasn't needed. 

Bottom line, best place to get the answer you need is to contact each carrier that your client HAS A CONTRACT with and ask them this exactly "How do we add a provider to our network contract"?  They will give you the procedure.    Your other question PRIOR to this was more about what a group was, how it's defined, etc and I'm again stating this isn't a part of the scope of our services and should not be something we consult with or about.  JMHO.

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Please answer me.

This is a public forum, it's not like we receive emails with an urgent requirement to respond. Some of us frequent daily and others weekly or whenever we can find the free time as a courtesy.

Linda Walker
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www.billerswebsite.com
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RichardP

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Re: Billing for lcsw
« Reply #9 on: April 07, 2013, 12:45:23 PM »
Linda, thanks for the comments.

... while Richard gave you CMS guidelines they are indeed different where mental health is concerned in credentialing with group health plans.

And now I've learned something.  As I stated, I don't know mental health billing.  Which is why I started off by saying these are my assumptions, and my response is based on these assumptions.  If my assumptions are not correct, then my answer should be suspect - since I do not know mental health billing.

... it's not up to a medical billing to define a legal entity.

This really wasn't about defining a legal entity.  It was about asking who was paying the lcsw.   Then I gave some background information for why that would matter in the case of a Nurse Practitioner - since Healthy said s/he was new to the process.  Again, if my assumptions were not correct, my response would be suspect.  But I hoped my response would draw more useful details out of Healthy.

So - I have a question about mental health billing, if Linda or anyone else can answer it:

For regular medical care, a Nurse Practitioner can bill in their own name, for less pay, and if they are properly credentialed.  Or they can bill in the name of their employer, for 100% of what the employer is entitled to.  If they are being paid for their work by their employer (whether solo practitioner or medical group), they NP cannot put their Type 2 NPI number (who gets paid) on the billing form.  They must use the Type 2 NPI number of whoever is paying them.  If the employer is paying the NP, it only matters if the employer is a participating provider.  When using the Type 2 NPI number of the employer, payment of charges will be at the participating provider rate if employer is a participating provider - regardless of whether the NP is credentialed as participating.

Does any one know if this is also true for an lcsw?

... it's not up to a medical billing to define a legal entity.

But, if medical billers need to become consultants in order to survive going into the future, then knowing something about what I've stated in this thread, and what is stated in the link I provided in my first post above will be useful in the role of consultant.

PMRNC

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Re: Billing for lcsw
« Reply #10 on: April 08, 2013, 06:56:38 AM »
The reason I don't get involved in setting up entities or even answering questions is because there are many variables including IRS guidelines, Stark guidelines, and general legal issues. Especially in the medical industry where the wrong setup could land a practice in hot water. Oh and also because my attorney says it best to stay out of that part. (my favorite reason)  I also do NOT involve myself with the practice marketing of patients for  similar reasons.
Linda Walker
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Healthy

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Re: Billing for lcsw
« Reply #11 on: April 08, 2013, 07:06:48 AM »
Richard thank you very much for all your help, this forum needs more people like you. God bless you.
PMRNC, I don't know why you assumed that I am asking you a legal aspect of entity, all I asked was how to bill?
Also I did not force you to answer my question, it was a humble request to all members of forum that "please answer me".it does not say that urgent answer is requested.

PMRNC

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Re: Billing for lcsw
« Reply #12 on: April 08, 2013, 07:26:43 AM »
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PMRNC, I don't know why you assumed that I am asking you a legal aspect of entity, all I asked was how to bill?

I did NOT assume you asked any such thing, I know you did NOT, it was brought up as a response to your question on how to bill. I agree you did not ask about groups or legal entities. Richard did however go above and beyond in his answer I was responding to that as I did not want to confuse you further with What if scenario's since you did only ask about the billing. With credentialing and mental health there most certainly is a difference in how it's done to accommodate the MANY TPA's that major carriers use.

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Also I did not force you to answer my question, it was a humble request to all members of forum that "please answer me".it does not say that urgent answer is requested.

I apologize as it did look like an air of impatience, so I just wanted to clarify the positions here. 
Linda Walker
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Healthy

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Re: Billing for lcsw
« Reply #13 on: April 08, 2013, 07:48:24 AM »
PMRNC, thank you. I love you all.

RichardP

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Re: Billing for lcsw
« Reply #14 on: April 08, 2013, 01:11:52 PM »
Healthy, this post is for you - but others may benefit from it.  And thank you for your kind words.

I don't know mental health billing.  But I know about regular medical billing.  My thought on reading your initial post was, if mental health billing is anything like regular medical billing, I see some confusing statements in your initial post.

You mention provider, lcsw, and Group all together in your initial post.  You state that provider has hired lcsw.  So I think we are talking about the requirements of a solo practitioner.  But the inclusion of the word Group makes me think that you are actually talking about a Group.  It will either be a collection of medical workers who have no rules imposed on them by CMS, and you just called them a group.  Or it will be a collection of workers who meet the CMS definition of a Group.  If it truely is a CMS-defined Group, then certain requirements are imposed by CMS that the Group must meet in order to be considered a Group by CMS.  One of those requirements is that the Group must do the hiring and paying, not the individual provider who is a member of the Group.  So the fact that you said the provider hired the lcsw, but they were part of a Group, told me that I needed some clarification of your setup before I could address your question.  Plus, the fact that a solo practitioner can be classified as a Group by CMS further confuses the issue.

A biller cannot possibly bill regular medical correctly when dealing with a collection of workers unless they know what requirements distinguish a CMS-defined Group from a collection of workers who call themselves a group but don't meet the CMS requirements to be a CMS-defined Group.  I don't know mental health billing, but I'm willing to bet that this paragraph is as true for mental health billing as it is for regular medical billing.  Linda's comments brought up the issue of legal structure and whether any biller ever needs to be involved in determining that.  That is not the issue.  CMS imposes requirements on a CMS-defined Group that it does not impose on an arbitrary collection of workers who do not meet CMS requirements to be called a Group.  When someone asks questions about billing, and uses the term Group, whoever is answering the question had better be interested in what type of Group the questioner is talking about.  Elsewise, any answers given may be incorrect.

Healthy, hopefully you found an answer to your question somewhere in all of this.  If not, or if you are still unclear on anything, come back with more questions.

[Edit] CMS imposes certain requirements on solo practitioners and Groups when they bill for Medicare patients.  The State of California imposes those same requirements on California providers regardless of what Insurance Carrier they bill.  Specifically, California also has adopted the CMS definition of Group, and makes the same distinction between solo practitioner and CMS-defined Group that CMS makes - regardless of what Insurance Carrier they bill (whereas CMS only makes that distinction for billing Medicare patients).  That is why I use the phrase CMS-defined Group above.  In California, we have to be mindful of the definitions and requirements set out by CMS, regardless of what Insurance Carrier we bill.  For us, in certain situations, how we bill depends on whether we are dealing with a solo practitioner or a CMS-defined Group; this is required by the California Code.  A health-care attorney can tell you whether anything like this exists in your state. [/Edit]
« Last Edit: April 08, 2013, 02:14:33 PM by RichardP »