Q: Why would I need a National Provider Identifier number if I never plan to electronically bill insurance or managed health care companies?
A: By May 23, 2007, counselors will need a National Provider Identifier number whether they bill an insurance company electronically, through a website or via paper HCFA.
Let’s back up a minute, however, and explain the NPI process. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires that all health care providers have a National Provider Identifier (NPI). This NPI will replace the various provider identification numbers (ID numbers issued by insurance companies) that counselors use to bill insurance and managed care companies. Therefore, each counselor will have just one ID number (the NPI) to use for every insurance and managed health care company. Most health plans, private health insurance issuers and all health care clearinghouses must accept and use NPIs in standard transactions by May 23, 2007.
You can obtain an NPI (if you haven’t already!) by doing one of the following:
- Apply online. The web address is http://nppes.cms.hhs.gov. This is a free service.
- Apply via snail mail. A copy of the application form, which includes the enumerator’s mailing address, can be found at http://nppes.cms.hhs.gov. Counselors may also call the enumerator and request a blank application form. The telephone number is 800.465.3203 or 800.692.2326 (Text Telephone).
- Submit an organizational application. With your permission, your employer or professional association can apply for NPI on your behalf. In addition, a service provided by a group called NetSource Billing will apply for an NPI number for you for a $25 fee. If interested, contact NetSource Billing at 866.441.1591.
Once you have obtained your NPI, don’t use it until May 23, 2007, or until you are notified by the various insurance and managed care companies. The word from Blue Cross Blue Shield is that it will notify counselors "when they can begin submitting their NPI on standard electronic transactions prior to the May 23, 2007, compliance date."
An additional note: We cannot emphasize enough the importance of credentialing through the Council for Affordable Quality Healthcare (see our June 2006 column in Counseling Today). This is a free service where you apply once, and more than 100 managed care and insurance companies will be able to access your information, saving you the time of applying to each individual company. At our last private practice seminar in Chicago in June, most participants were unaware of CAQH and its benefits. Go to CAQH.org and apply online or request a paper application.
Q: I am in a group private practice. I am credentialed with most insurance companies, including most of the major managed care companies. I am planning on leaving the practice to start my own individual practice but have heard some concerning stories about people who have tried to leave group practices only to find out that some of the insurance companies were going to drop them. Reportedly, the reasoning is that they are not contracting with individual providers at this time. Have you heard about this? Is there any way around this? Your thoughts would be appreciated.
A: The reason you may be dropped from a managed care or insurance panel is not because they aren’t contracting with individual providers. Most will accept solo practitioners if there is a need in your geographic area or niche.
The problem has to do with payer ID. The group probably bills under its tax ID, and you cannot use that number once you leave. According to an authority with the Value Options provider relations department, you have to recredential with those panels you want to be in again. We suggest you apply once to the Council for Affordable Quality Healthcare (see previous question) as a shortcut to the recredentialing process.
If the group uses your tax ID (one that is solely yours), you are in good shape. Our contact at Value Options tells us all you must do in that instance is file a "change of address" with each insurer. We hope this helps.
Q: Can an insurance company deny coverage to a client because he or she had counseling or was prescribed medication under a previous policy? Check out the article "Prozac: Hazard to Your Health Insurance" in MSN Money by Debora Vrana (http://articles.moneycentral.msn.com/Insurance/InsureYourHealth/ProzacHazardToYourHealthInsurance.aspx). I thought HIPAA kept records private, but perhaps insurance companies have a way around this to use past records for denying coverage?
A: We checked with two sources. A billing expert told us that insurance companies follow HIPAA in that they do not share database information and therefore cannot look for pre-existing conditions in that way. The expert advised counselors to refuse to release notes on any clients; this is your right under HIPAA.
However, a person usually must fill out a questionnaire if changing insurance. This is where a new insurance company can find out about a pre-existing condition. If it is a new group policy with coverage through an employer, there may be a waiting period, usually for one year.
The counselor does not have to fill out the section of the Health Insurance Claim Form that asks about pre-existing conditions to be paid by the insurer. That is, unless they direct the counselor to do so after a claim has been processed.
This is an excerpt from the MSN article: "The majority of Americans get insurance through their employers, who in turn pay a large portion of the monthly premium. Large groups of diverse workers help offset the risk for insurers. The individual market is much more risky for insurers, however, because the individual pays the premium and there is not a diverse pool of people. The market for non-group insurance is a small one in the U.S., with roughly 6% of the population under 65 covered by such a policy, according to a study by the Rand Corp."
It’s true that those clients with non-group insurance are more at risk for denials for pre-existing conditions or even being denied insurance at all. We advise discussing these issues with the client and including it in your informed consent document so they can make a decision on whether to access their mental health benefits paid by insurance. Ask clients if they have had counseling before under a different insurer because you may not be paid for their current treatment.
Note: We always advise counselors to consult an attorney about these issues. Our advice is based solely on our experience and is not legal advice.
Robert J. Walsh and Norman C. Dasenbrook are the co-authors of The Complete Guide to Private Practice for Licensed Mental Health Professionals (www.counseling-privatepractice.com). ACA members can e-mail their questions to firstname.lastname@example.org and access a series of free bulletins on various private practice topics on the ACA website at www.counseling.org.