TABLE OF CONTENTS
“Navigating the Insurance Maze, The Therapist’s
Complete Guide To Working With Insurance”
by Barbara Griswold, LMFT

1. WHY TAKE INSURANCE?
2. UNDERSTANDING INSURANCE
   • Deductibles, Copayments, Co-insurance, Provider Networks / Panels
   • Employee Assistance Program (EAP), Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), Exclusive Provider Organization (EPO), Point-of-Service Plan (POS)
   • A Comparison of Plans
   • Making Choices That Fit Your Practice
   • Health Savings Accounts (HSA), Medical Savings Accounts (MSA) ,Health Reimbursement Arrangements (HRA) and Flexible Spending Accounts (FSA)
3. EMPLOYEE ASSISTANCE PROGRAMS: A CLOSER LOOK
4. MYTH OR REALITY?
   • If I Take Insurance,…
     • I’ll Have to Do Billing and Lots of Paperwork?
     • I’ll Have to Discount my Fee?
     • Sessions Will be Limited?
     • My Therapy Will be Micromanaged by Idiots?
     • All the Networks are Full?
     • Clients Will Have to Get a Doctor Referral?
     • I Have to Give Diagnoses to Clients?
     • I’ll Have to Deal with HIPAA?
5. BECOMING A NETWORK PROVIDER: SELLING YOURSELF TO INSURANCE COMPANIES
   • Why You Should Have a “Managed Care Resume”
   • Your Letter of Interest
   • Applications
   • Single case and Transition-of-Care Agreements
   • Most Frequent Fees Paid for Therapy
6. TALKING TO THE INSURANCE COMPANY: WHO TO TALK TO, HOW TO GET THROUGH
   • Navigating the Automated Phone System
7. PARITY, HIPAA, AND HEALTH CARE REFORM: LEGAL JUNK YOU NEED TO KNOW
   • Parity Laws
   • HIPAA : The Health Insurance Portability and Accountability Act
   • Health Care Reform: The Affordable Care Act (ACA)
8. STARTING THERAPY: CHECKING COVERAGE AND INTAKE SESSIONS
   • First Contact: Why You Should Call the Insurance Plan – Now
   • Checking Coverage: 13 Essential Questions – A Worksheet
   • Translating “Insurance-Speak”
   • Care Denials: Bad News Before Treatment Begins
   • The First Session
   • Reasons for a Treatment Agreement
   • The Insurance Card – And Why You Shouldn’t Trust It
   • The Perils of Private Pay: When A Client Doesn’t Tell You About Coverage
9. GETTING MORE SESSIONS: AUTHORIZATIONS AND MEDICAL NECESSITY
   • What Case Managers Look For: “Medical Necessity”
   • A Sample Treatment Update
   • Authorization Requests: Dos and Don’ts
   • Why Your Request Might Get a Closer Look
   • Retro-Authorizations and Extensions
10. ONGOING THERAPY
    • Losing Coverage
11. GETTING PAID: SUBMITTING CLAIMS AND INVOICES
    • If You Are a Network Provider
    • If You Are an Out-of-Network Provider
    • Line by Line Instructions to The CMS-1500 Claim Form and Sample Form
    • Claims Tips
12. THE CHECK ARRIVES – OR DOESN’T: THE EXPLANATION OF BENEFITS AND DENIALS
    • A Sample Explanation of Benefits (EOB)
    • Understanding the EOB, and What to Do When You Get it
    • Why Your Claim Might be Denied
13. APPEALS: FIGHTING DENIALS
    • The 10 Rules of Successful Telephone Appeals
    • Steps to Appealing a Denial and Specific Appeal Situations
    • Sample Appeal Letter
14. ELECTRONIC BILLING – WITH OR WITHOUT A COMPUTER
    • Submit Directly at the Insurance Plan’s Website
    • Submit Through a Claims Clearinghouse with a Billing Program
    • Submit Through a Claims Clearinghouse Without a Program
    • Submit Through a Billing Service
    • What’s In It For Therapists?
15. CLINICAL ISSUES AND CONFIDENTIALITY
16. 13 EASY WAYS TO JEOPARDIZE YOUR LICENSE: COMMON TYPES OF FRAUD
17. COUPLES, FAMILIES, AND “DOUBLE COVERAGE”
    • Couples or Family Therapy
    • Double Coverage: When A Client or Couple is Covered by Two Plans
    • Primary and Secondary Insurance: A Chart
18. LIFE AS A NETWORK PROVIDER
    • What’s Expected
    • Resigning
    • Provider-Profiling
    • Audits and Site Visits
    • If You’d Like More Clients – or Less
19. SHOULD I ACCEPT INSURANCE?
    • A Self-Quiz
    • Taking Care of Yourself: The Secrets of Sanity
    • Getting a Raise

APPENDIX A: STATE INSURANCE DEPARTMENTS
APPENDIX B: RESOURCE LIST
APPENDIX C: GLOSSARY
APPENDIX D: SAMPLE TREATMENT AGREEMENT
APPENDIX E: SAMPLE INVOICE/SUPERBILL
APPENDIX F: SAMPLE SESSION TRACKER
APPENDIX G: SAMPLE PRIVATE-PAY AGREEMENT

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