Health and wellness professionals are known for their passion for making a significant impact on their clients' well-being. However, passion alone won't pay the bills. To ensure your business thrives, you need fair compensation for your expertise and services. For many practitioners, this involves dealing with medical insurance billing.

Insurance billing, when done accurately, can ensure swift payment. However, the complexity of the process means there's much that can go wrong. This article discusses the five most common problems wellness professionals encounter when dealing with insurance billing, along with advice on preventing them in your business.

Headache 1: Claim denials

Though there's limited data on the frequency of claim denials in insurance billing, one report suggests insurers deny between 10% and 20% of claims. Regardless of the true number, denied claims represent a drain on your business – both in terms of cash flow and the administrative load associated with following up. 

Amy Plano (aka The Reimbursement Dietitian) teaches dietitians how to use health insurance as a profit tool in their practices – in addition to running her own highly successful nutrition private practice. “There are so many reasons for insurance denials,” says Amy. “However, the majority of these mistakes are user errors. This is usually due to provider knowledge gaps.” 

Here are some of the most common reasons for claim denials:

• Incorrect or missing client information on claims. For example, the name on your claim doesn’t match the name in the insurance company’s system.

• Missing pre-authorization. Some insurance plans require pre-approval before you can perform a non-emergency treatment. Others may require a referral from the primary care provider. 

For example, if a primary care physician (PCP) diagnoses a patient with a medical condition that requires nutritional counseling, the PCP can make a referral and include the correct ICD 10 codes (International Classification of Diseases) on insurance billing forms.

• Medical insurance billing and coding errors. You must include both ICD-10 and Current Procedural Terminology, or CPT codes, on your CMS-1500 form when billing insurance. Choosing the wrong codes will result in payment delays and denials.

According to Amy Plano, these types of errors often occur when a practitioner delivers counseling by telehealth. They then use an incorrect code to represent telehealth on the insurance claim. Or, a practitioner assumes they are billing under the preventive side of a patient’s insurance policy. That will make the ICD 10 codes they enter on a claim inconsistent with the service provided. 

“Each insurance company classifies preventative MNT (Medical Nutritional Therapy) services differently,” according to Amy. “This information is available on insurance companies' websites under preventative services. Providers are required to know how to bill for these services.” 

• Eligibility issues. If the insurance provider believes the treatment isn’t covered by a client’s plan they can deny the claim. Many health insurance companies won’t cover procedures that they deem to be experimental or unproven.

In a dietitian’s practice, Amy says this can happen if a practitioner doesn’t properly verify the MNT benefits beforehand. If the patient doesn’t have coverage on their plan for the conditions the provider billed for, it will be denied. 

Solutions for avoiding claim denials

1. Establish quality control measures. Conduct a thorough review of your paperwork before you submit a claim, and stay informed about payer policies to reduce the chances of claim denials.

2. Know your codes. With so many billing codes and variations, mistakes can easily happen. Check and double-check your entries to ensure accuracy. 

Handy tools to help with code look-up:

• ICD-10-CM browser tool offered by the Centers for Disease Control
• American Academy of Professional Coders (AAPC) also offers a lookup tool for CPT codes
• American Medical Association (AMA) provides resources to search the 2024 CPT code set

3. Verify ahead of time. Ever heard the phrase "it’s better to beg for forgiveness than ask permission?" That doesn’t apply to medical insurance billing. “Unless you’re familiar with the specific insurance policy, you should always verify benefits ahead of time,” says Amy. 

4. If all else fails, appeal. The Affordable Care Act protects the right of patients and their providers to dispute denials from insurers.

Headache 2: Credentialing and contracting

Credentialing is the process of proving your qualifications and professional background to an insurance company. It’s the first step in how to become an in-network provider. Credentialing ensures providers in the system meet an insurer’s standards for delivering services. 

Contracting comes after successful credentialing. It involves negotiating and signing a legal agreement with an insurance company. This agreement outlines the terms and conditions of services, agreed-upon reimbursement rates, and more. Once the contracting goes through you can begin submitting for services provided.

Common issues with credentialing and contracting: 

• It’s time-consuming. The entire process for each insurer you apply to can take months and it’s easy to get buried in paperwork and admin. 

• Errors and omissions. Transpose two digits in your National Provider Identity (NPI) number and your wait to get credentialed will be even longer. In fact, any incorrect or missing data on your forms will lead to delays in being accepted as an in-network provider. 

• It’s not one-and-done. That’s right: re-credentialing is a thing and the timeframes will vary from as little as one year up to several years. Frequency depends on whether you work with commercial payers or Medicare/Medicaid.

If you neglect to re-credential on time your claims will get denied. The resulting gap in coverage means patients pay out of pocket or you create a Superbill so they can file for direct reimbursement. Both can negatively impact the client experience you’ve worked so hard to cultivate.

Solutions for avoiding credentialing issues

1. Start early and be choosy. Credentialing can be a long process. The earlier you start, the earlier you can start billing payers directly for your services. 

Credentialing with a larger network of payers might sound like a great way to grow your practice, but getting credentialed with all of them is even more time-consuming. A smaller subset of plans or insurers may work well with the services you provide. Talk to your colleagues about the insurance market in your area or ask clients directly about their insurance providers to look for overlap. 

2. Be meticulous. Double- or even triple-check your applications. Errors create delays in credentialing and payment delays in the future if they slip through. Once accepted as an in-network provider, information on your future submissions must match what you stated at the credentialing stage. 

3. Create a centralized repository. Keeping all your certifications, licenses and other relevant documentation in one place streamlines the application process. (e.g., NPI number, tax ID number, malpractice insurance documents, and more). Note, your practice management software can also be a tool to organize your insurance billing profile. 

4. Use process checklists. Since credentialing can take months, it’s helpful to keep an accurate record of which steps you’ve completed and which still need to be done. For example, note when you submitted the application, any follow-up items, additional items requested by the insurance company, and an estimated timeframe for completion. 

5. Register with CAQH (Council for Affordable Quality Healthcare).  CAQH provides a data portal that can be accessed by providers and insurers. While optional, submitting and maintaining your credentialing details through CAQH keeps everything centralized. You create a single credentialing application that’s accepted in all 50 states, then authorize the insurance companies you want to work with to view your profile. 

Headache 3: Verification of benefits

Performing a verification of benefits before you provide services ensures you will receive payment from a client's insurance. Checking ahead helps you understand things like coverage limitations, deductible realities, referral requirements, and copayment or coinsurance rules. 

Failing to verify benefits can cause: 

• Denied claims due to a lack of coverage. 
• Unexpected out-of-pocket expenses for your clients. Although it may be annoying to find out ahead of time that a service isn’t fully covered, it trumps getting hit with a bill they aren’t expecting or can’t afford. 

Solutions to avoid verification of benefits surprises 

1. Be proactive. Collect and verify patients' information and insurance coverage when they schedule their appointment. You can even make it part of your intake process so you have time to verify coverage before the first appointment.  

2. Use the tools. Many payers offer the option to check for eligibility through their dedicated portal. You can also speak with a representative over the phone, but wait times can be quite long. Clearinghouses like Claim.MD, which is integrated with Practice Better will also offer verification of benefits services.  

3. Document the details. Maintain meticulous records of all interactions and information gathered during the verification of benefits process. This documentation is invaluable to reference in the event of any disputes.

4. Embrace change. Insurance coverage may change if a client switches jobs or shops around for a different provider. Ask clients regularly if there are changes to their coverage, and build processes to perform periodic re-verification checks. 

Headache 4: Changing regulations and codes

You need the right codes to get paid quickly and correctly, but those codes always seem to change. Staying up to date on the most recent changes can be challenging. 

• CPT codes - Note that Category 1 CPT codes, which are the ones providers use to indicate healthcare services and procedures, are updated yearly and go into effect on January 1 of each calendar year. 
• In the US, insurance billing requires ICD-10-CM (where CM for Clinical Modification) to provide more details on claims. ICD-10-CM codes are updated twice a year, in April and October.

How to keep up with code and regulation changes: 

1. Stay informed. Make sure you review any communications from the insurance companies you deal with, as they will communicate changes and how they impact you. 

2. Be proactive. Many industry organizations offer affordable training, webinars, and conferences on the topic of medical insurance billing and coding. For example, the AAPC offers options from a single webinar at $65 USD, to a subscription for several hundred dollars a year.

3. Tap into your professional network. Your professional association may also offer resources to help you stay updated. For example, The Academy of Nutrition and Dietetics in the US has a resource center with information on health insurance, payment models, coding requirements, billing practices and more.

Headache 5: Delayed payments

Beyond the usual culprits of inaccurate documentation, coding errors, and credentialing and contracting delays, insurance companies frequently have backlogs that can slow reimbursement. 

Delayed payments can greatly impact the financial health of your business. So, let’s explore some solutions for avoiding this common pitfall. 

Solutions for avoiding payment delays: 

1. Processes matter. Stay up to date on regulations and codes, implement efficient billing processes, regularly follow up on unpaid claims, and establish clear communication with payers to reduce payment delays.

2. Stay on top of billing. Getting bills out promptly can help keep cash flow steady. You can simplify your processes and speed up reimbursements by having robust billing functionality built into your practice management software. 

3. Document everything. A clinician's favorite phrase. If you do need to follow up with a payer on reimbursement delay, make sure to keep pristine records. For example, if you speak with an insurance rep on the phone, make sure you record their full name, the day and time of the call, and any notes regarding what you discussed. If there are follow-up items discussed, ask for a confirmation in writing by email. 

Note, all states (except South Carolina) have rules requiring insurers to pay or deny claims within a certain time frame, known as “prompt pay” laws. These laws apply to “clean claims” which means claims with no errors. You can navigate your way to filing a complaint on the NAIC website by selecting your state from the drop-down on the home page.

Getting paid doesn’t have to be painful

The administrative burden associated with how to start billing insurance companies can loom large for practitioners. It’s expensive, too. According to the Center for American Progress, U.S. payers and providers spend about $496 billion a year on billing and insurance-related (BIR) costs. 

You can keep your costs (and headaches) down by following the tips in this article for avoiding common insurance billing pitfalls. Practice Better also has an insurance integration built-in to help with streamlining your insurance billing success. Not a customer yet? Claim your free trial. 

Practice Better is the complete practice management platform for health and wellness professionals. Streamline your practice and begin your free trial today.