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Before You Can Bill: Medical Credentialing 101 Guide for Therapists​​

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What do I need to know for my therapy practice credentialing?

Is medical credentialing for therapists different from credentialing for other kind of healthcare practices?

We get asked these questions all the time.

The process of medical billing and paying is known as the healthcare revenue cycle. Credentialing with local insurance companies is typically the first step in the process.

While building an effective and profitable revenue cycle is indeed complicated, it is certainly doable if you put in the time and effort.

Before You Can Bill: Medical Credentialing 101 Guide for Therapists

Before You Can Bill: Medical Credentialing 101 Guide for Therapists​​

Here Neolytix presents a 101 Guide to help therapists navigate the complex ins and outs of medical credentialing.

We’ll focus on several central features of the credentialing process such as licensing and provider enrollment.

We’ll also discuss some of the differences in credentialing between mental health professionals and other healthcare service providers, as well as which plans your therapy practice should consider credentialing with.

Table of Contents

Talking to counselor

1. Licensing for Therapists

Every state plus Washington D.C. and Puerto Rico requires licensure in order to legally practice as a professional counselor. These laws establish and enforce education, examination, and experience baselines for all therapists and counselors.

Professional therapists and counselors carry several different titles depending on the state they’re licensed in. These include

  • LPC: Licensed Professional Counselor
  • LMHC: Licensed Mental Health Counselor
  • LCPC: Licensed Clinical Professional Counselor
  • LPCC: Licensed Professional Clinical Counselor of Mental Health
  • LCMHC: Licensed Clinical Mental Health Counselor
  • LMHP: Licensed Mental Health Practitioner

While LPC is the most common, all these licenses are officially recognized by different states to signify a mental health professional.

While education requirements vary by state, getting licensed almost always involves completing a master’s degree in counseling.

Most states require 60 semester hours of graduate coursework plus 48-semester hours towards your master’s degree. The counseling graduate program must be accredited, with standards of accreditation varying by state.

You must also complete a certain amount of supervised experience hours in order to obtain your license. Most states require between 2,000 and 3,000 hours. These hours are comprised of general work experience as well as a minimum number of face-to-face supervision hours.

Finally, you must pass a comprehensive exam to complete your training and obtain your license. Tests include the following:

  • NCE: National Counselor Examination
  • NCMHCE: National Clinical Mental Health Counselor Examination
  • ECCP: Examination of Clinical Counselor Practice
  • CRCE: Certified Rehabilitation Counselor Examination

While the NCE is the most common, different states accept different examinations as meeting the testing requirements of licensure.

To find the accreditation requirements of your state, consult the Council for Accreditation of Counseling and Related Educational Programs. Visit their website at www.cacrep.org (good thing they abbreviated it!).

Related to CAREP, the Council on Rehabilitation Education or CORE (nice acronym!) is responsible for accrediting master’s programs in rehabilitation counseling.

Click here for detailed info on state licensure requirementsYou can also use this handy tool to quickly search requirements by state.

Medical credentialing is necessary for healthcare professionals to participate in health plan networks, provide care to insured patients, and receive in-network payment for their services.

Whereas licensure varies by state, enrollment requirements vary by health plan. Most carriers have standard forms to fill out, while some use online credentialing applications. The Council for Affordable Quality Healthcare (CAQH) has helped standardize enrollment methods in recent years. However, there is still quite a bit of variation between carriers.

Pay close attention to the individual health plan’s guidelines if you wish to join their network. Consider the services you provide, what a network will reimburse, and the kinds of populations you plan to serve.

Medical Billing for Mental Health Services

2. Credentialing for Therapists

Terms like “credentialing” and “enrollment” are sometimes confused. Let’s clarify this first.

The term “provider enrollment” can refer to enrolling a healthcare provider with an insurance company. However, it can also mean adding electronic remittance advice (ERA) to electronic health records (EHR), or a multitude of other things pertaining to the healthcare billing cycle.

For our purposes, we will stick to the term “medical credentialing” because “enrollment” is broad and can mean different things in different contexts.

Medical credentialing is necessary for healthcare professionals to participate in health plan networks, provide care to insured patients, and receive in-network payment for their services.

Whereas licensure varies by state, enrollment requirements vary by health plan. Most carriers have standard forms to fill out, while some use online credentialing applications.

The Council for Affordable Quality Healthcare (CAQH) has helped standardize enrollment methods in recent years. However, there is still quite a bit of variation between carriers.

Pay close attention to the individual health plan’s guidelines if you wish to join their network. Consider the services you provide, what a network will reimburse, and the kinds of populations you plan to serve.

For example, state Medicaid programs often cover other provider types that include mental health care, such as PCPs, clinics, or psychiatric residential treatment facilities.

States will have rules and statutes describing the types of providers that may provide mental health services.

For more information for mental health professionals to enroll in Medicaid, click here.

Speech Therapy Medical Billing & Coding Guidelines 2021

3. Credentialing Differences: Individual vs. Group NPI

One key difference to watch out for in the therapist credentialing process is individual NPI versus group NPI.

Every healthcare provider must obtain a national provider identifier number or NPI. This is a 10-digit number assigned to every healthcare provider by the Centers for Medicare and Medicaid (CMS).

When we say every healthcare provider, we mean every healthcare provider.

As an individual therapist, you will have an NPI. If you belong to a group practice organization or facility, that group will have its own NPI. Both the individuals and the group as a whole are considered healthcare providers.

Where this gets complicated is figuring out which NPI to use for services rendered and which to use for billing.

  • If you participate in an organization, your individual NPI number will appear as the individual healthcare provider on claims.
  • Then the group practice NPI will appear as the billing provider on that claim.

Obtaining an NPI—whether for yourself or for a practice you work with—is one of the first steps of the credentialing process. However, you must be very careful about which NPI you provide to which insurer.

If you are seeking to credential both a practice and its associated individual providers, ask the insurer to link the individual and group NPIs.

African therapist with folder in hospital

4. Which Plans to Credential With?

When looking for companies to partner with and networks to join, it is crucial to understand your clients and your area of operation.

Which insurance plans are popular in your area? What kinds of mental health services do they cover? What kinds of clients are you most likely to serve, and what are their primary needs?

Of course, there are the ‘Big 7’ payers:

  1. Tricare
  2. BCBS
  3. Aetna
  4. Cigna
  5. United Health
  6. Humana
  7. Medicare

(We’ve omitted Medicaid because many therapists do not have clients on Medicaid. In such cases, there’d be no point in credentialing. If you do anticipate serving patients with Medicaid, make Medicaid #8 on the list.)

If you don’t know or can’t find any information on which insurance companies are popular in your area, we recommend starting with these major payers.

However, always keep an eye out for popular local plans in your area. Once you find one, check whether the insurance company’s panel is currently accepting practitioners in your area of specialization.

After all, most major insurance companies require tons of paperwork, from completing the CAQH (the online medical credentialing database) to filling in all your personal details. You’ll need your education, licensing, training, and experience (past and present) information on hand and fully up to date.

Don’t put in all this work only to find out the insurer doesn’t cover patients in your area!

If you need help finding popular local plans, let us know!

Young Girl Talking With Counselor At Home

Conclusion

We hope this guide has helped in understanding the basics of medical credentialing for therapists.

Credentialing can be complex, time-consuming, and often costly. Smaller practices in particular often find the process difficult.

Neolytix cares about small therapy practices and wants to do everything possible to help your practice succeed.

If you’d like some additional assistance, please check out our full medical credentialing services.

Are you looking to turbocharge your marketing strategies? Check out this post on marketing for therapy practices.