Getting on Insurance Panels A Step-By-Step Guide When Starting a Practice 2013 by Daniel Bruns, PsyD In the field, it appears to be increasingly difficult for early career psychologists to get on insurance panels, so that they can provide services. Although I have no evidence to back this up, my belief is that this is a cost containment strategy for payers: By reducing the number of providers, they can reduce their costs. Unfortunately, this also means that policy-holders may have more difficulty getting the services they paid for. For those of you who are trying to start a practice, what follows are some approaches to consider. I cannot promise you that any of them will work, but these are things that you might try. Payer policies are a moving target: policies in place today may change tomorrow. Because of that, approaches that work today may not work tomorrow. It will be important for you to investigate all of the applicable federal and state laws, and also the contractual rules that apply to what you are doing. Always follow these rules and regulations and do the right thing. Using this as a foundation, and adding in some business savvy, it is possible to create a practice for yourself, and make a living. 1. First of all, identify the services you intend to offer, and document the need for them. For this purpose, it is important to identify a service that you can offer for which there is a need in your area, such as performing pre-surgical psychological evaluations. Presurgical psychological evaluations are an especially good example, as payers require them before a person can have surgery, but then may refuse to place providers on their panel that can offer them. That s not fair. 2. Dutifully fill out all of the forms required by the payer, and send them in (make copies for your records). Make a case for what you do. 3. Seven to ten days after you have sent the forms in, call to make sure the forms have been received. These forms get lost with astounding frequency. In the process, find a contact person at the insurer that you can follow-up with. 1
4. For each payer, document each time you mail, e-mail, fax, or call the person and what was said. This will help build your case. 5. If you get on the panel, great. If not, further steps will be needed. 6. Becoming a Medicare provider is generally easier. Through the process of seeing Medicare patients, you may have met some local physicians and developed a relationship. Market your services to those physicians. Ask them if they would be willing to write a letter to payers in your areas. You might actually try writing a draft letter for them saying: To Whom It May Concern: Dr. Smith is a health psychologist who offers Service X to medical patients. We have an unmet need for Service X in our community. Because of this, I would strongly recommend that you allow Dr. Smith to be on your panel. Tell the physicians that if you get on the panel, you will help them with their difficult patients. That will motivate them. 7. Similarly, it may be possible to form a relationship with a hospital, saying that you can help with follow-up care for patients after discharge. Under the ACA, hospital are penalized for readmits. 8. If it possible to develop a relationship with an employer, they may be able to write a letter to their payer also, getting you on their panel. a) You might try building a relationship with an employer by offering to do a free lunch and learn stress management program for their employees. If after this, their employees would like to work with you, but their insurance won t allow it, that might also encourage the employer to assist you. 2
b) More simply, you might say I will donate some free services to your company, that I think you will find valu able. If you do find it valuable, I would ask that you write a letter advocating that I be place on your insurance panel. i. Offer something generic like stress management ii. Don t let it become an I hate the company support group or this will really backfire on you. 9. Now we go to the next phase. Write to the payer again, but this time saying, a) I have mailed you 18 times and you have not responded. b) There is a need for my services in this community. c) Attached see request by physician, Dr. Smith, advocating that I be placed on your panel. d) Attached please find letter from Ms. Jones of Human Resources at business X, requesting that I be placed on your panel. e) I feel that is unreasonable for you to deny me a place on your panel, when there is an unmet need for my services in this community. f) Copy this letter to both the state insurance commission, and to your state representative and state senator. Depending on the laws of your state, the insurance commission could be moderately to very helpful. The most helpful person might be your state representative - the person who represents your district. If you are trying to start a business in the community, they can often be helpful. If you donate a $100.00 to their reelection committee, they can be even more helpful. Make sure to ask for two bumper stickers. It is not uncommon for a state representative to assign a staffer to write a short letter on your behalf. Payers really don t like having state congressmen and the insurance commission 3
involved. Therefore, this can be very persuasive. If you organize a $10,000 a plate fundraiser for the congressman, you can be the next Insurance Commissioner. I am engaging in hyperbole here, but sometimes this is a political process. 10. Along the way, you might want to have one or two excellent research studies to mention supporting what you do something that you can literally summarize in 10-15 seconds, but can back up if needed. You should try to establish that there is a need for your services in the community, that your services provide better care, and that your services also save money (as health psychology services are often cheaper than their medical alternatives). 11. Some payers have resorted to saying that they will not put psychologists on panels unless they have x number of years past licensure. I am not sure if this is legal, as they are attempting to create two levels of licensure. They are saying that even though the state licenses someone to practice, that is not enough for them, and they require more. If a payer is taking that position, you might ask an attorney if that is legal to do in your jurisdiction. I don t know how they can say that some licenses to practice are valid, while others are not. I cannot of course give you any legal advice, but this is something that you may need to look in to. 12. If there are no other providers providing your service within a 25-mile radius, some payers offer reimbursement for out-of-network providers. 13. There are often advantages to joining a practice with someone who is established. Suppose Dr. Jones joins Dr. Smith s practice a) Some insurance contracts have overflow provisions. That is, if Smith is too busy to see a referral in a timely fashion, Smith can refer the patient to Jones as overflow under Smith s contract 4
b) Medical contracts almost always have a locum tenens provision for temporary fill in services. This clause could be in Smith s contract as well. c) Jones may be allowed to see a patient incident to Smith. That is, Jones sees the patient, but is supervised by Smith and bills under Smith s license and contracts. There are many rules to follow to do this, but in some areas this is widely done. 14. Miscellaneous thoughts: a) For the health psychologist, deciding which panel to apply for (medical or mental health) can be a difficult choice. In carve out contracts (where mental health is a separate payer), being on the medical panel may boot you off of the mental health panel, and vice versa. The medical side is usually harder to get on, but may reimburse at a higher rate. b) When trying to get on medical panels, ask the payer if they have neuropsychologists on their panel. Many medical payers do, because as a discipline neuropsychology has been around longer than health psychology, and have been proactive for their professional practice. If they do have neuropsychologists on their panel, note So actually you do allow psychologists on your panel. Think of me as being like a neuropsychologist, except that I deal with organs other than the brain. Sometimes health psychologists can be admitted to a medical panel under the neuropsychology provision for psychologists if the payer looks in the right place in their contract. Because some insurers only allow neuropsychologists on their panel, some payers ask neuropsychologists to do things that they are not trained in, such as presurgical psych evals for liver transplants. The reason for this apparently is that neuropsychologists are the only psychologists on their medical panel. c) The trend in the field at this time appears to be away from everybody being in independent private practices. In the coming years, there will likely be an increasing trend for psychologists, and especially health psychologists to be more closely integrated with larger health delivery systems, like Accountable care Organizations. It may be possible for you to have a contractual relationship with a 5
medical facility of some sort, or alternately become an employee. In this regard, health psychologists may have more opportunities than clinical psychologists. As a health psychologist, talk to a facility that specializes in what you do. If you have a contractual relationship with them to provide services for them, they will likely advocate for you with the payer. In some cases, there are bundled payment arrangements, where the payer pays one price for a combination of medical, nursing and psychological services, and then the clinic distributes the money. 15. Talk to your state psychological association, and to an attorney if you have legal questions about these matters. Find an attorney who specializes in health care law. If the payer is not following the law, a letter from an attorney to the payer can be helpful. A letter from the insurance commission is likely more helpful about any infractions, as they can impose sanctions on a payer, and these regulatory activities do not involve costs on your part. On the other hand, if you have an attorney, that person works for you. 16. Health and behavior codes are of course a whole different animal. For that see the following document: http://www.healthpsych.com/tools/resolving_h_and_b_problems.pdf Dr. Bruns has been a practicing health psychologist in Greeley, Colorado for 27 years, where he specializes in the assessment and treatment of patients with pain and injury. He has served on Colorado state task forces and advisory panels that developed medical treatment guidelines for chronic pain, chronic regional pain syndrome, traumatic brain injury and other guidelines, and also served on the American College of Occupational and Environmental Medicine panel that developed the 2008 Chronic Pain Treatment Guidelines for worker s compensation. His work is cited by the Official Disability Guidelines, and he was on the advisory panel for the AMA Guides to The Evaluation of Permanent Impairment, sixth edition. For the American Psychological Association, Dr. Bruns is the National Chairperson for the Health Psychology Clinical Health Services Council. In 2008, Dr. Bruns received a Presidential Award for his contributions to the field from the American Psychological Association s Division of Health Psychology. In 2010, he received the Timothy Jeffery Award for his contributions to the field of health psychology from the American Psychological Foundation. Dr. Bruns is a coauthor of the BHI 2 and BBHI 2 psychological tests. He is also the coauthor of numerous research articles and book chapters on the role of psychology in the medical setting, including articles on presurgical psychological evaluations, and the assessment of psychological risk factors for patient violence and litigiousness. 6