Insurance Billing Basics: The Complete Guide to Getting Started with Insurance for Private Practice

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In this short tutorial from Jill Shook, CCC-SLP, you can learn the basics of what it takes to start accepting insurance in private practice.
Click to skip to a section:
00:00 Introduction
0:31 Insurance Vocabulary
2:53 Credentialing requirements
4:30 Contract process
6:15 Providing Therapy as a Provider
7:12 Tips for Confirming Benefits
9:52 Submitting Claims
12:28 Getting Paid
Outline:
1. Basic Vocabulary:
- EMR/EHR : Electronic Medical Record/Electronic Health Record. HIPAA-compliant digital versions of paper charts that include patient information, notes, evaluations, and insurance info.
- Claim: the invoice/bill you submit to an insurance company. It includes information like the NPI of the treating clinician, ICD-10 (diagnosis) code/s, CPT (procedure) code/s, and the patient’s insurance info
- Some people use the term superbill, invoice, and claim interchangeably, but that’s not correct. Those are all slightly different documents.
- Clearinghouse: An intermediary between you and the insurance company that checks claims for accuracy and forward the claim to insurance companies through a process called "claims scrubbing". Having a clearinghouse is required by most insurance companies.
- EOB: Explanation of Benefits. A form that explains why an insurance company accepts or rejects a claim. Sent to the patient and the provider (will look different for each)
- EFT: Electronic Funds Transfer. A direct deposit from insurance, allowing them to pay you without having to mail a paper check.
- ERA: Electronic Remittance Advice. Information from the insurance company about why a claim was or was not accepted. The electronic form of an EOB.
- Superbill: an itemized form that shows what treatment you provided, the diagnosis, your license number and EIN, and the patient’s insurance information.
2. The Credentialing and Contract Process (Becoming A Provider)
1. This is when insurance companies check your licenses and practice information and decide if they will approve you to become a provider
a. Set up a free CAQH Proview account, and have the following information ready:
- Employee Identification Number (EIN)
- National Provider Identifier (NPI)
- State license number
- Business name, if you have formed an LLC or other business structure
- ASHA number if you have one- it is not required by most companies, but gives additional information
- Professional Liability Insurance coverage paperwork
- Taxonomy code (for SLPs, it is 235Z00000X)
2. Once credentialed, check your contract or the provider page for their fee schedule is and if they have any special requirements like:
a. mandating the session length for specific CPT codes (e.g. some companies require that 92507 be 1 hour long, even though that code is not timed).
b. If there is a required clearinghouse to use in addition to an EMR (Availty, Navinet, etc)
3. Providing Therapy as a Provider
a. Before seeing your first client, verify their benefits, either through the number on their membership card or through your EMR.
b. Info you need about the benefits:
- co-payment- a flat fee that is due at certain medical visits, usually $20-50.
- coinsurance : a percentage of the cost of the procedure, which the patient pays, and/or
- deductible: an amount that the patient must meet yearly before insurance will pay. Coinsurance and co-payments may figure into this, depending on the plan.
4. Submitting claims
a. After the session, write up a claim, usually on a CMS 1500 claim form.
b. Simple Practice will auto-populate the form for you from your session notes.
- Date/s of service
- ICD-10 (diagnosis) codes
- CPT (procedure codes) and any modifiers
- Place of service (location code)
- Rendering provider with your NPI
- Billing Facility (this would be your Type 2 NPI)
- The patient’s address, insurance information, and date of birth
c. Submit claim it to the clearinghouse that is required by the insurance company (most can be submitted through SimplePractice)
i. Make sure you submit the claim within the Timely Filing requirements, which can vary by insurance company! Many companies allow 365 days from the date of service, but some only allow 90.
5. Getting Paid
a. In most cases, you will receive your ERA directly to your EMR
b. This can take anywhere from a few days to a few weeks (or, in some cases with Medicare or Medicaid, a month or two).
c. Once the claim is accepted, you will be paid by the insurance company, either through an EFT directly into the account you specify or through a paper check.
Learn more: www.simplepractice.com/featur...
Jill Shook and SimplePractice are providing this information for educational purposes only and it does not substitute for accounting or legal advice.

[@ManekaAgarwal]

Thank you so very much Jill. Just what I needed....simple, clear, and concise....may you always stay blessed!

[@dragonfly8973]

Thank you for a simple demystifying of being a provider. WOW! It has helped me immensely.

[@cnboyle]

Just started an admin job with a counselor and this was super helpful! Thank you!

[@jackiekettelkamp7934]

Thank you for your simple explanation!!!You made it much easier for me to understand the process.

[@kimcampbell4752]

Awesome! Everything I needed to know to get started in the right direction.

[@ms.jessicakesvlogs6300]

You are a great speaker. I can follow you very well. Thanks for this.

[@Simplepractice]

So nice of you!

[@monicarubio3818]

Thank you for your knowledge, so appreciate you and really don't take your knowledge for granted!

[@karlaraegateley2579]

Thank you for a very clear and helpful presentation! You packed an amazing amount of information into 13 minutes.

[@Simplepractice]

You're very welcome Karla!

[@blacksmith504]

Great video. Having a nightmare scenario with my PT practice's billing company and have decided to take it into my own hands and start learning. This is exactly what I needed to start. Thank you for posting.

[@Simplepractice]

Thank you so much for that great feedback!

[@bernfran1313]

Thank you. This was straight to the point. I'm studying Medical Coding. We briefly touch on the Billing aspect while learning about diagnoses and procedures. I'm yet to understand why all insurances don't bill for the same amount... It's business, bottom line, the dollar/profit.

[@daniellemarshall3251]

Thank you for this video God bless you!

[@charlestaylor378]

I have avoided going into a full-time private practice in speech-language therapy for several years just because of insurance billing fears. I just found the entire process to be far too complicated. Thanks to your video, I am re-thinking things. While the process still entails numerous steps, you have taken the mystery out of the process. Thank you. I look forward to more of your informative videos!

[@80monia]

Hello, any updates that you'd like to share? I'm thinking about starting my own private practice.

[@rhondarhoades910]

Thank you. This video was extremely helpful.

[@abbyrupert5555]

Very clear and well presented.

[@amandacollins759]

Great job! I just learned so much in a short time!

[@Simplepractice]

Glad it was helpful!

[@asifkaka5052]

Damn I was applying for a medical billing company and your video gave me a very good idea of what I am going to be doing for the next couple of months. Hopefully

[@ajassimanwar]

Thanks for simplicity of your explanation

[@Simplepractice]

Glad it was helpful!

[@Manish-no4uu]

Very well explained, thanks!

[@janetm2405]

This was awesome information. Thank you!

[@jaimemartinez9586]

Great information! Thank you so much!

[@collectsmobilelab5895]

Awesome information! Thanks so much!

[@Hopefully2025]

Thank you! Very clear!

[@chinnayadav6024]

Thank you.given great knowledge

[@TerminalVelocityable]

This is an excellent video

[@waynelittle5071]

Pittsburgh in the house! Thank you for this video!!

[@AskTheBiller]

I’m a certified and licensed AAPC medical billing instructor and just wanted to say, well done!!! The content in this video is on point.👌🏾

[@eliana6474]

Fantastic video! Thank you! ⭐️ ⭐️ ⭐️ ⭐️ ⭐️

[@jefferson9687]

This was helpful, thank you!

[@zennagirl8324]

That was really helpful. Thank you for making this video.

[@Simplepractice]

You're very welcome!

[@dstalktime5551]

Soooo informative. Thank you!

[@dashawna333]

Thank you so much for this information

[@davidjones5319]

Great overview!!!

[@muhammadakmal9302]

thank you for information 😊

[@battamohammed8869]

Helpful.. Thanks

[@littlestation3222]

good information! thanks

[@iamnancy3709]

Thanks this helped me sooo much!

[@Simplepractice]

Glad it helped!

[@thespiritofyou1836]

Simplepractice, do you offer mileage expense report tracking?

[@monicarubio3818]

If you use Simple Practice, what do you use to store your EHR files and patients/clients files?

[@akhilapalem2633]

Thank you , that was really usefull

[@Simplepractice]

Glad it was helpful!

[@soniasamuels8544]

Great info!!!!!

[@barbaracharles9143]

the best detailed information. much appreciated

[@sapphirephysiciancoding4309]

Awesome!

[@amberblock6041]

Is there an online Medical Billing course available that you suggest?

[@Deanzphx]

Cool video

[@chewie1355]

Can CMS 1500 paper forms still be used?

[@XxThingsThatRawrxX]

what clearing house should I use to verify benefits instead of having to call and ask every time?

[@stylzplusbeautyandhairconc839]

Do you file claims for other businesses?

[@user-yp3ls7lz2p]

Is there knowledge on whether you submit a claims form when they have PPO and are paying their deductible?

[@jasonmarch1983]

Technically a clearing house is not required if you get setup directly with the insurance to submit edi (is a pain for most companies) but could be worth it if you do many claims or have very little payers. Since it is almost always free with no limits

[@africalib78]

I did not know this. I thought you always needed a clearing house!

[@jasonmarch1983]

@@africalib78 yeah most of them use some form of ftp just connect you computer, it shows the folder and drop the the edi(s) file in. they set you up with the user name and password.

[@randolphwright3990]

So the clearing house is basically a middle person to review your claim before it gets to the insurance and if you are set up with the insurance company you don't need a clearing house right? Or does the insurance require it?

[@jasonmarch1983]

@@randolphwright3990 yes Clearing House is a middle man that pre-processes your claims prior to sending to claims dept. Many insurance companies use specific Clearing houses. Fees are common between sending claims between clearing houses. So another way to get free claims. Is to register with every Clearing House your payers use. If your emr has an edi setting per insurance. (Even the free openemr does) when you export your claims it will batch correct claims to correct clearing house. This can save considerable on fees.

[@olakunleadewaleadegbile5301]

I like the video

[@DreaLightrider]

What is a naics code? Started filing with highmark and they are requiring it I can't submit without it.

[@tf2640]

Amazing video and just what I've been searching for. Do you have more? Do you have contact information?

[@Simplepractice]

Glad it was helpful! We just published two new videos about insurance, or you may be interested in our "Ask A Biller" video series, all about insurance billing.

[@monicarubio3818]

Do you think I should go to school to take medical billing classes? In order to get my clinic started to working with the insurance companies?

[@Dana-kc7gl]

I’m trying to start my own practice as well. Did you go through with it?

[@sikanderzahoor788]

🤗🤗🤗🤗 love you dude for such information but I have required some more information how can I contact you

[@melaniegrooms6556]

I start school for medical billing next month on the 27th and I'm sitting here wondering what I got myself into hahaha!

[@Simplepractice]

Hi Melanie, how was your first week? You'll be teaching these courses in no time! :)

[@alexandrtimofeev11]

It’s much easier than it seems. If you would like to ask some questions I can help you :)

[@amberblock6041]

Are you taking these classes online? I'd be interested in looking into this, since I'm just getting started with Medical Billing as well.

[@MrMT-gt9xm]

I believe you may have answered ...i may have asked to early

[@MrMT-gt9xm]

Thank you, do you know how to verifiy the isurance company

[@KP-tx9gq]

What is an insurance write-off? My agency charges $200 per session collects a copay of $35, leaving $165 insurance charge. Insurance paid $50, contractual obligation is is $114 and appears as a write-off. Please make it make sense.

[@cmr5180]

If the provider is in network with the insurance, they have a set of fee that they will charge based on the provider-insurance contract. The provider will normally write their charge but the insurance will only pay what was agreed upon and the remaining balance will be written off. Nobody will pay for it.

[@vaghanmikaelian1923]

If a doctor charges the insurance company $1,500 for services and the insurance company pays only $100 per contract rates what happens to that $1,400 balance? Does the Doctor only make $100 for a service that would have cost an uninsured patient $1,500?

[@BeauTEAfulT]

Yes

[@jerryshah6706]

Online classes medical billing