The Ultimate Guide to Billing Insurance in 2024

The decision around whether you should be billing insurance for your wellness services is deeply personal. It can encompass factors like quality of care and your personal philosophy around care accessibility. However, choosing to accept insurance can also impact how you run your practice, the selection of services you provide, and even your relationship with your clients. 

From a pure business perspective, billing insurance for your wellness services is a valid way to expand your client base and diversify your income streams. It’s definitely worth a deeper look, and we’ve done the digging for you. 

Keep reading to understand why billing insurance can be great for business, the nuances between different plans, and how to bill insurance as a provider – including staying compliant, navigating denials, and coding like a pro.

Advantages of billing insurance 

When you think about how to bill insurance as a provider of wellness services, it might evoke images of increased paperwork and jumping through hoops. In reality, insurance billing solutions can offer a sustainable revenue stream for your business. 

• Being part of an insurance network can significantly expand your client referrals.
• Clients may be more apt to come for repeat visits (and year after year) if they have insurance to help mitigate the cost.
• You get the opportunity to serve clients who might not otherwise be able to pay out of pocket for access to your skills and expertise. 

Understanding the basics of billing insurance

You need a National Provider Identity number (NPI) to bill any insurance provider. This unique 10-digit identifier is a permanent number assigned to individual healthcare providers or organizations by the Centers for Medicare & Medicaid Services (CMS). 

An NPI helps to accurately identify you and smooths out the billing processes with insurance companies.  HIPAA (the Health Insurance Portability and Accountability Act) also requires that all covered entities have an NPI. The application is free and the turnaround time to receive your NPI usually takes between 1 and 20 days.

Although your NPI remains the same no matter which insurance company you’re dealing with, there are subtleties you should understand about the different insurance plan types.  

Your NPI number can then go into your Practice Better account to automatically add to Superbills and CMS 1500 forms.

Differentiating between insurance plans

Your clients may have private insurance or coverage from a government-run program  – either Medicare or Medicaid. 

Just as the name suggests, private insurance is run by private companies, like Blue Cross Blue Shield and Aetna. 

• Private insurance can offer individual plans, employer-sponsored plans, or marketplace plans. Also known as “health insurance exchange,” marketplace plans were created under the Affordable Care Act (ACA) to help individuals and small businesses purchase health insurance. 
• Private insurance plans will vary significantly across criteria like coverage, deductibles, co-pays, and size of network. 

Medicare and Medicaid are both administered by a federal agency called the Centers for Medicare & Medicaid Services – or CMS. There are some key differences between the two programs. It’s also possible for some individuals to qualify for both Medicare and Medicaid, which provides them with superior coverage. 

MEDICARE

MEDICAID

Federal health insurance for people 65 or older, certain younger individuals with disabilities, and people with end-stage disease. A person’s Medicare coverage is the same no matter what state they live in. People with Medicare pay some of the costs. This can take the form of monthly premiums, deductibles, and coinsurance.

A jointly funded federal-state program providing health coverage for eligible low-income individuals/families.  All Medicaid programs have to follow general rules, but eligibility and coverage vary since it’s administered by individual states. Medicaid also offers benefits that Medicare doesn’t cover, like nursing home care and personal care services.  People with Medicaid don’t pay anything for covered expenses, but they are sometimes required to make co-payments for particular items or services.

HMO (Health Maintenance Organization) vs PPO (Preferred Provider Organization) 

HMOs and PPOs are two popular types of managed healthcare plans offered by insurance providers in the United States. These plans involve networks of healthcare providers and offer different levels of coverage, costs, and flexibility. Here are some key differences between the two: 

• Network
  • HMOs have a more limited network and require referrals for specialists. Providers in the network have typically agreed to charge lower rates for plan members. 
  • PPOs offer a broader network and don’t typically require referrals. PPOs also have fewer restrictions on seeing non-network providers.

• Care
  • There are typically more restrictions for coverage in HMO plans – e.g., requiring clients to select a primary care provider (PCP), or only allowing a certain number of visits or treatments. Care is only covered if clients see providers from within the defined network.
  • PPO plans provide more flexibility when choosing healthcare providers. (i.e., clients can see the specialist they’d like to without a referral from their PCP.)

• Costs
  • HMOs usually have lower out-of-pocket costs (like premiums) but offer less flexibility
  • PPOs offer more flexibility but often at a greater cost (e.g., higher premiums and deductibles). They may reimburse out-of-network visits at a lower rate. 

Key terminology you should be familiar with

When you’re working through how to bill insurance as a provider, knowing the common terms used helps to navigate the landscape more easily. Here are five key terms every wellness professional should know. For a more complete listing, you can check out the CMS glossary.

1. Deductible: This refers to the amount a client is required to pay out of pocket for covered services before their insurance kicks in. 

Usually, deductibles outline how much a person is expected to pay per calendar year. Some plans will waive deductibles for certain activities, like office visits. Others have them applied to all services. 

2. Co-payment (Co-pay): This refers to a fixed dollar cost a client pays for covered services. It’s usually paid at the time of service. The amount often varies depending on the provider (e.g., are they in-network?) and the type of service being provided. 

So, for example, imagine a dietitian is providing a first-time nutritional counseling session at a rate of $200 for an hour. The client’s insurer might require the client to pay $20 directly to the practitioner. The insurer would then reimburse the remainder directly to the practitioner. 

3. Co-insurance: Many insurance plans require covered individuals to pay for a percentage of the allowed amount after they have met the deductible requirements. This amount can be in addition to the fixed co-pay required as well.

For example, a client might have a $40 co-pay for a $300 therapy visit. This is a fixed amount they pay at the time of their appointment. Their plan may also include a 20% co-insurance payment. This would make them responsible for paying 20% of the amount after their deductible is met. 

4. Pre-authorization/Pre-approval: Some insurers want to provide approval for non-emergency services before they’ll cover the cost. It’s up to them to decide whether the service, treatment plan, drug, or equipment is medically necessary. However, be aware that getting preauthorization doesn’t guarantee that the insurer will cover the cost in the end. 

5. Explanation of Benefits (EOB): This is a statement insurers provide explaining which services they paid for and explanations for why any claims might have been denied. It typically lists the amount billed, the allowed amount, the amount paid to the provider and any co-payment, deductibles, or coinsurance charged.

Eligibility verification and patient information

Accuracy matters when you’re billing insurance for your services. Errors can lead to disputes, delays, and lost revenue for your practice. It can also be stressful for your clients if claims are denied and you need to approach them to pay out of pocket for the cost of your services. 

You’ll want to ensure that you have all the client details correct when you’re submitting claims for reimbursement. Name, address, date of birth, insurance member ID number, relationship to the insured person, etc. are all important pieces of information to get right the first time. 

Make sure to verify coverage details, including deductibles, co-pays, and more. A client presenting you with an insurance ID card is not proof of eligibility. There are typically a few different options you can use to verify eligibility. 

• Payer portals – Private insurance companies offer online portals where you can enter a client’s information to determine their eligibility. 

• Calling the insurance provider – Putting a call into the provider will get you accurate answers. It can be time-consuming, but automated voice systems help to speed up the process. 

• Use a clearinghouse – A medical billing clearinghouse will electronically submit claims to insurance companies on your behalf for a fee. They add value by verifying client eligibility, checking claims for errors, and generally speeding up efficiency. They also have in-house insurance billing experts that you can tap to answer your burning billing questions.

• Insurance billing solutions – Software solutions will also typically give you tools to check a client’s eligibility before you provide services or determine if certain services demand pre-approval from the insurer. 

• Note that government-funded programs also offer tools to check for eligibility. Medicare offers resources and guidance on this topic. Since Medicaid coverage varies by state, there are a variety of portals and hotlines available. You can find contact information for each state program using the search tool on the Medicaid website. 

Navigating different insurance billing systems

When you’re billing insurance claims to private companies versus government programs there are some similarities and differences to keep in mind.

Best practices for CMS 1500 form completion in private insurance

All providers use a standard insurance claim form, whether submitting to private insurance, Medicare, or Medicaid. It’s called a CMS 1500 and it requires specific information to process the claim. This includes client demographics, provider information (like NPI, location and address), policy information, and diagnosis and treatment information by entering the correct ICD-10 (International Classification of Diseases) codes and CPT (Current Procedural Terminology) codes.

Common billing errors

• Using an outdated CMS-1500 form – You can get the most up-to-date copy of the form from a variety of locations, including many office supply stores, the U.S. government bookstore,  Amazon, and even your practice management software. 

• Omitting important information – Leaving fields blank or inputting the wrong information, either yours or your clients, can result in claim delays and denials.

• Lacking specificity – Your diagnosis code (ICD-10 code) has to be as specific as possible. There is often a range. For example, if you’re treating a client for obesity, the main ICD-10 code is E66 – Overweight and obesity. You can also add more numbers to this root to provide more context on the factors contributing to the condition. For example, E66.01 indicates Morbid obesity due to excess calories. 

• Inappropriate use of CPT codes – Many CPT codes are timed codes, meaning they’re associated with treatments of a certain length of time. Using the wrong codes can result in over- or under-billing your services. Even worse, it can raise the flag for potential fraud. Common issues include:
  • Unbundling, which means using multiple CPT codes for a single service when one code would do. 
  • Upcoding, which means using the wrong code at a higher reimbursement rate. 
  • Adding modifiers, which are the two-digit codes you add to a CPT code. In some cases, modifiers can also signal higher reimbursement that you don’t qualify to receive for the treatment provided. 

• Timing – Some insurance providers require that you file claims within a certain number of days after delivering a service. The best practice is to submit within 30 days.

Coordination of benefits 

Some clients will be covered by multiple insurance plans, for example, if both they and their spouse have private insurance coverage through their employers. Coordination of benefits involves determining which insurance plan is primary when a client is covered by multiple insurance policies. This helps in determining which plan pays first for healthcare services. It also helps clients receive maximum benefits while minimizing out-of-pocket costs. 

Billing considerations for Medicare and Medicaid

Remember: Medicare is a federal program so the rules are more consistent across the board:

• Medicare sets reimbursement rates based on a fee schedule. The rates can vary by service and geographic location. 
• Reimbursement fee structures for non-physician providers, like dietitians, physical therapists, and chiropractors, may also differ from the published physician fee schedule. Coverage may also be more limited. 

Medicaid reimbursements vary by state, but there are some general rules to follow: 

• Make sure beneficiaries are eligible for reimbursement when it comes to the services you provide. There are often specific criteria around medical necessity.
• Medical records must be accurate, legible, signed, and dated. 
• CPT codes must accurately represent the treatments provided.
• Overpayments must be returned within 60 days. 

Medicare and Medicaid offer different models of managed care, including HMO and PPO options. Care providers who want to become part of the network negotiate contracts which also outline reimbursement rates, terms, and conditions for services provided to plan members.

• These contracts ensure predictable reimbursement rates for you, so you can better plan your finances. 
• Contracts also outline compliance with quality standards and billing practices required by the insurer and other regulatory agencies. 

Troubleshooting and handling denials

Here are some tips for avoiding the headache of billing insurance providers denying your claims and what to do if it happens regardless of your vigilance. 

• Stay on top of frequent changes to payer policies. Sign up for newsletters, emails, or those online portals we discussed earlier to receive updates on policy changes, coding updates, and billing guidelines.
• Be accurate. Check and double-check the information and codes you fill out on your forms. 
• If claims do get denied, check the Explanation of Benefits to see why. You might need to call the payer to get further clarification. There’s often the opportunity to correct and resubmit for payment. 
• Protect yourself. Make sure your clients are aware of policies for payment in the event of claim denials. Are they responsible for paying the full amount of denied claims? Will you issue them a Superbill to try and collect reimbursement themselves? Making sure clients understand and agree to your policies ahead of time can save you from awkward conversations down the line. 

Telehealth billing

Remember when the pandemic forced everyone to figure out telehealth really fast? That extended to the U.S. Department of Health and Human Services (HHS). They made administrative changes to relax the rules around telehealth and make it easier to access, deliver, and get paid for services. Some of these changes are permanent and others are temporary. 

As rules and reimbursements for telehealth continue to evolve, you can stay up to date through the telehealth HHS hub. on through the HHS.

Common CPT Codes for health and wellness professionals

The correct use of CPT codes is critical for accurate billing and reimbursement. This standardized set of codes is used to describe medical, surgical, and diagnostic services provided to patients in the U.S. healthcare system. 

• Codes are developed and maintained by the American Medical Association (AMA). 
• Note that Category 1 codes (those used for healthcare services and procedures) are updated yearly and those changes go into effect January 1 each year.

Here are some common CPT codes that wellness professionals use regularly.

Common CPT codes for Physical Therapists

CPT CODE	DESCRIPTION	NOTES
97110 – Therapeutic exercises	Therapeutic procedures necessary to improve a person’s strength, endurance, range of movement, and flexibility.  It covers one or more parts of the body and requires direct contact with a qualified professional, such as a physical therapist.	Time-based code, billed in 15-minute increments
97140 – Manual therapy techniques	Features hands-on techniques including mobilization/manipulation, manual lymphatic drainage, and manual traction.	Time-based code, billed in 15-minute increments
97530 – Therapeutic activities	Cover therapeutic activities over a wide range of rehabilitation exercises. Therapy focuses on mobility, strength, balance, and coordination.	Time-based code, billed in 15-minute increments

Common CPT codes for Nutritionists/Dietitians

The three CPT codes dietitians use most are outlined below. Private insurers, Medicare, and Medicaid all accept these codes. 

CPT CODE	DESCRIPTION	NOTES
97802 – Medical nutrition therapy; initial assessment	This code is for an initial face-to-face assessment and intervention with an individual client. It’s used by providers who treat conditions and symptoms using dietary and nutritional therapy.	Time-based code, billed in 15-minute increments. Can only be used for the first visit with a client.
97803 – Medical nutrition therapy; re-assessment and intervention	This code is for follow-up visits. It covers ongoing assessment/treatment using nutritional therapy.	Time-based code, billed in 15-minute increments.
97804 – Group medical nutrition therapy	This code is for treating a group of clients (2+) using dietary and nutritional therapy.	Time-based code, billed in 30-minute increments of a session to a group of two or more patients.

Common CPT codes for Chiropractors

CPT CODE	DESCRIPTION	NOTES
98940 – Chiropractic manipulative treatment (CMT), one to two regions	The provider applies manipulation to influence joint and neurophysiological function by a variety of techniques and modalities in one to two spinal regions – spinal, thoracic, lumbar, sacral, or pelvic.	Manipulation limited to 1 – 2 regions.
98941 – CMT; spinal, three to four regions	The provider applies manipulation to influence joint and neurophysiological function by a variety of techniques and modalities in three to four spinal regions – spinal, thoracic, lumbar, sacral, or pelvic.	Manipulation limited to 3-4 regions.
98943 – CMT; extra-spinal	The provider applies manipulation to one or more of the extra-spinal regions – head region, lower extremities, upper extremities, rib cage, abdomen.	Manipulation to 1 or more regions.

Common CPT codes for Clinical Psychologists

CPT CODE	DESCRIPTION	NOTES
90791 – Under psychiatric diagnostic evaluation	The provider delivers a psychiatric evaluation of a new behavioral health concern with the intent of making a diagnosis.	Typically billed for the initial appointment, between 16 and 90 minutes in length.
90832 – Individual psychotherapy, 30 minutes	The provider performs psychotherapy, a series of techniques for treating the psychiatric disorders of the patient. The treatment session with the patient typically lasts for anywhere between 16 to 37 minutes.	90832 should be billed for sessions between 16-37 minutes. Other codes cover longer sessions:  90834 (between 38 and 52 minutes) 90837 (53 minutes or more)
96130 – Psychological testing, evaluation, and feedback	The provider administers standardized psychological tests, including interpreting results, establishing a treatment plan, and preparing a report.	Code covers the first hour of this service. Each additional hour needed to complete the service is billed with the code 96131.

Compliance and regulations

In 2022, the Office of Inspector General (OIG) reported healthcare fraud judgments and settlements accounted for over $3 billion. Complying with medical billing rules requires charging accurately for your services and following the guidelines and laws set out by federal and state governments, Medicare, Medicaid, and private insurance companies. 

• Federal and state laws cover many aspects of billing insurance, including fraud, privacy, and security of patient information.
• The Centers for Medicare & Medicaid Services has outlined specific guidelines for billing. These encompass medical necessity, and accurate coding/documentation.
• HIPAA (Health Insurance Portability and Accountability Act) regulations are in place to protect your clients’ protected health information, or PHI. Health and wellness practitioners who are billing insurance for their services must stay in compliance with HIPAA to avoid financial penalties and/or legal action. 
• Private insurance companies each have their specific guidelines when it comes to billing. Make sure you follow them to avoid disputes, denials, audits, and other actions that can erode your credibility and profitability. 

Tips for navigating compliance 

You can stay in compliance by ensuring you code accurately, document everything, conduct regular audits, and thoroughly train any staff who are tasked with billing insurance. 

• Billing codes are constantly evolving. Not only do Category I CPT codes get updated once a year, but ICD codes also change, albeit over a slower timeline. 

The transition from ICD-9 to the current ICD-10 increased the number of codes by 13,000. ICD-11 actually came into effect on January 1, 2022, but it’s up to individual countries to decide when they will transition to the updated codes. For context, the World Health Organization (WHO) endorsed ICD-10 back in 1990, but the HHS transition to the new codes didn’t take place until October 2015. 

• Embrace technology to help you manage compliance. Insurance billing solutions have built-in safeguards to protect PHI and tools to assist in assigning accurate diagnosis and procedure codes. They also push regular compliance updates and provide audit trail and reporting functionality. Many practice management solutions also include this functionality, helping to streamline the billing process, reduce errors, and improve workflows. 

Common ICD-10 codes for nutrition and mental health professionals

ICD-10 codes are a standardized system used worldwide to classify and code various diseases and health conditions. They are used to help insurers understand the diagnosis related to any treatment and, as such, are an integral part of healthcare billing in the U.S. 

Here are some common ICD-10 codes wellness professionalss use every day.

Physical Therapists:

• M25.50 – Pain in unspecified joint – falls under chapter 13 – Diseases of the musculoskeletal system and connective tissue
• M54.5 – Low back pain. Includes:
  • M54.50 Low back pain, unspecified
  • M54.51 Vertebrogenic low back pain
  • M54.59 Other low back pain
• M75.4 – Impingement syndrome of shoulder. Includes:
  • M75.40 Impingement syndrome of unspecified shoulder
  • M75.41 Impingement syndrome of right shoulder
  • M75.42 Impingement syndrome of left shoulder

Nutritionists/Dietitians:

• E78.0 – Pure hypercholesterolemia. Includes:
  • E78.00 Pure hypercholesterolemia, unspecified
  • E78.01 Familial hypercholesterolemia

• E66.9 – Obesity, unspecified. You can include an additional code to identify body mass index (BMI), if that information is known.
  • BMI codes fall in the Z68 range and provide further quantitative information about a client’s health which can help strengthen the case for reimbursement.

Chiropractors:

• M99.01 – Segmental and somatic dysfunction of cervical region
• S13.9XXA – Sprain of joints and ligaments of unspecified parts of neck, initial encounter

Clinical Psychologists:

• F32.9 – Major depressive disorder, single episode, unspecified – excludes bipolar disorder (F32.-), manic episode (F30-), recurrent depressive disorder (F33.-)
• F41.1 – Generalized anxiety disorder

Stay savvy when it comes to insurance billing 

When it comes to how to bill insurance as a provider, the landscape is constantly changing. But the complexity shouldn’t deter you from giving your business access to a lucrative revenue stream. 

The key to staying successful with billing insurance is to stay informed (and the right software has a big role to play too)! We can help. Sign up to our mailing list to get the latest updates on insurance billing solutions delivered to your inbox. 

Practice Better is the complete practice management platform for health and wellness professionals. Streamline your practice and activate the Claim.MD integration to bill insurance seamlessly.