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-> Working Women
amother
OP
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Sat, Dec 31 2022, 9:50 pm
I'm looking all over the internet and cannot find this information. I'm a speech therapist with a specific niche that's needed. Right now I'm working for an agency that's paying me very little. I would like to start working privately and billing insurance. Am I doing something wrong ? I can't even find out how much medicaid reinburses never mind the in/out of network private insurance companies.
Anyone have any clue or knows any information.
Thank you so much!
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amother
Goldenrod
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Sat, Dec 31 2022, 10:45 pm
Which Medicaid HMO are you asking about?
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amother
OP
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Sat, Dec 31 2022, 10:49 pm
Any.
Or out of network coverage is what I'm really trying to find out.
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amother
Goldenrod
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Sat, Dec 31 2022, 11:23 pm
You don’t want to deal with NJ Medicaid.
Not worth it.
Aetna better health pays $45 per session.
Amerihealth pays you a monthly fee (about $200 monthly) and you’re spossed to give the child as much therapy as is needed. If you do it once a week it comes out to about $50 per session. Twice a week would be $25 per session. So you can basically only do once a week, unless you want to lose money. Sometimes you can get more for a child if you can prove they need it, but you can’t do that for more than 1 or 2 clients or it’d be suspicious.
I don’t know anyone who takes WellCare or Horizon NJ Health so I’m guessing their rates are even worse.
United Healthcare kicked everyone off about 4 years ago. They aren’t contracting with most local providers at this point, and after the audits and gehinnom everyone went through with them I wouldn’t touch them with a ten foot pole, even if they WERE willing to make a contract.
Bear in mind that the paperwork for Medicaid takes a huge amount of time, so you have to factor that into your cost.
Bear in mind also that Medicaid’s modus operandi is to audit retroactively and demand money back left and right - do a google search on it. So unless you’re willing to invest in a good healthcare lawyer (think fees of $500-$1000 an hour for a LOT of hours) and a coder, and/or you’re willing to take the risk of having to return a lot of the money you earned down the line, I’d say it’s idiotic to take Medicaid.
Signed,
Owner of a private practice in Lakewood who knows-from experience- you’re taking a huge risk if you take Medicaid
(And, as you see, their rates STINK)
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amother
OP
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Sun, Jan 01 2023, 7:43 am
Goldenrod thank you so much for your detailed response! Wow the rates do stink I'm shocked !
Would you know about the better out of network insurances how much they pay ? Because I know therapist that take those and seem to be making a lot.
Thank you so much for all your help!
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amother
Papaya
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Sun, Jan 01 2023, 8:23 am
I don't know what the reimbursement rates are but I know that many insurances don't have any out of network coverage. Parents get stuck paying cash for their children's needs and often it's really difficult
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amother
Goldenrod
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Sun, Jan 01 2023, 10:16 am
For private insurances:
Aetna pays $68.40 in network
Bear in mind that many people, even with in network coverage, are subject to deductibles, almost everyone has a copay (which you MUST charge legally) ranging from around $20-up to $50.
Aetna also often denies if it’s a just a language or articulation disorder, saying developmental issues aren’t covered.
Out of network with Aetna, if parents have it - which is rare, pays anything from $50-$90 per session.
BEAR IN MIND THAT ALL OUT OF NETWORK COVERAGE IS SUBJECT TO THE DEDUCTIBLE AND COINSURANCE, AND MOST INSURANCES GIVE 30 SESSIONS PER YEAR, SO BY THE TIME THAT’s MET, YOUR 30 SESSIONS ARE NEARLY USED UP.
THEREFORE, EVEN IF YOU MAKE A TON PER SESSION ITS ONLY FOR A FEW SESSIONS UNLESS YOU HAVE A KID WITH AN AUTISM DIAGNOSIS WHO IS ELIGIBLE FOR UNLIMITED YEARLY SESSIONS UNDER THE STATE MANDATE.
Horizon pays approximately $75 per session in network. Out of network their allowed amount is $156 per session, after the deductible and coinsurance are met.
I don’t take Cigna, United Healthcare, or Oxford in network, because I was told it’s hard to make a contract with them and their rates are poor.
Out of network Cigna usually pays $156.
United Healthcare pays anywhere from $65-$156
Oxford pays anywhere from $70-$195
Remember again that these are after the deductible and coinsurance have been met. Also, many people don’t have any out of network benefits.
And again, without an autism diagnosis, you will spend part of their 30 sessions just going towards the deductible and coinsurance.
One more thing - in order to get these high rates, you have to charge them. If you charge less, you get paid less. But legally, you have to charge both the parents who are private pay and the insurance based clients the same. So you have to have a legal financial hardship document explaining why the parents aren’t paying the same as insurance. It’s complicated.
Most practices only have very few (if any) clients where they’re making those rates. You get lucky if you have an autistic client with private insurance with out of network benefits…
Now the agencies who service kids with autism on the other hand…
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amother
OP
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Sun, Jan 01 2023, 10:24 am
amother Goldenrod wrote: | For private insurances:
Aetna pays $68.40 in network
Bear in mind that many people, even with in network coverage, are subject to deductibles, almost everyone has a copay (which you MUST charge legally) ranging from around $20-up to $50.
Aetna also often denies if it’s a just a language or articulation disorder, saying developmental issues aren’t covered.
Out of network with Aetna, if parents have it - which is rare, pays anything from $50-$90 per session.
BEAR IN MIND THAT ALL OUT OF NETWORK COVERAGE IS SUBJECT TO THE DEDUCTIBLE AND COINSURANCE, AND MOST INSURANCES GIVE 30 SESSIONS PER YEAR, SO BY THE TIME THAT’s MET, YOUR 30 SESSIONS ARE NEARLY USED UP.
THEREFORE, EVEN IF YOU MAKE A TON PER SESSION ITS ONLY FOR A FEW SESSIONS UNLESS YOU HAVE A KID WITH AN AUTISM DIAGNOSIS WHO IS ELIGIBLE FOR UNLIMITED YEARLY SESSIONS UNDER THE STATE MANDATE.
Horizon pays approximately $75 per session in network. Out of network their allowed amount is $156 per session, after the deductible and coinsurance are met.
I don’t take Cigna, United Healthcare, or Oxford in network, because I was told it’s hard to make a contract with them and their rates are poor.
Out of network Cigna usually pays $156.
United Healthcare pays anywhere from $65-$156
Oxford pays anywhere from $70-$195
Remember again that these are after the deductible and coinsurance have been met. Also, many people don’t have any out of network benefits.
And again, without an autism diagnosis, you will spend part of their 30 sessions just going towards the deductible and coinsurance.
One more thing - in order to get these high rates, you have to charge them. If you charge less, you get paid less. But legally, you have to charge both the parents who are private pay and the insurance based clients the same. So you have to have a legal financial hardship document explaining why the parents aren’t paying the same as insurance. It’s complicated.
Most practices only have very few (if any) clients where they’re making those rates. You get lucky if you have an autistic client with private insurance with out of network benefits…
Now the agencies who service kids with autism on the other hand… |
Wow thank you so much goldenrod!!! You are a wealth of knowledge!
I'll admit this is way more complicated sounding than I originally thought it would be.
Thank you so much for your help!
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amother
Goldenrod
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Sun, Jan 01 2023, 10:41 am
I suggest - I’d you think you can get clients - just charging out of pocket. If parents want to submit to their insurance for reimbursement - no problem.
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amother
Navyblue
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Sun, Jan 01 2023, 12:14 pm
There's a reason why most therapists who don't work independently don't take insurance. I'd suggest that you look for a better paying agency first. Or if you can fill up your slots with private pay, go for it. I have jersey care and tend to pay out of pocket for these things because it's cheaper than getting a good insurance plan.
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amother
Zinnia
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Sun, Jan 01 2023, 12:23 pm
amother Navyblue wrote: | There's a reason why most therapists who don't work independently don't take insurance. I'd suggest that you look for a better paying agency first. Or if you can fill up your slots with private pay, go for it. I have jersey care and tend to pay out of pocket for these things because it's cheaper than getting a good insurance plan. |
no such thing as a better paying agency. they all pay us too little its terrible.
OP just charge out of pocket if youl have enough of a clientele and if you have a niche you can offer
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amother
Goldenrod
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Sun, Jan 01 2023, 12:45 pm
amother Zinnia wrote: | no such thing as a better paying agency. they all pay us too little its terrible.
OP just charge out of pocket if youl have enough of a clientele and if you have a niche you can offer |
I’m just curious what you are being paid and why it’s terrible. Can you share that information?
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amother
Zinnia
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Sun, Jan 01 2023, 1:11 pm
amother Goldenrod wrote: | I’m just curious what you are being paid and why it’s terrible. Can you share that information? |
65$ an hour. Doesnt factor into account absences, YT, sick days, school trips, no health benefits...I make the same every month as my friend thats a secretary
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amother
Goldenrod
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Sun, Jan 01 2023, 5:23 pm
Okay I hear that IS low. Are you in NY or NJ?
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amother
Zinnia
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Sun, Jan 01 2023, 8:57 pm
Recently moved to NY from lakewood
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amother
OP
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Sun, Jan 01 2023, 9:01 pm
I get between $70-$75 depending on agency but it's EI so no payment for travel time/gas..
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amother
Goldenrod
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Sun, Jan 01 2023, 10:51 pm
As an agency owner, I pay $75 and up (depending on experience…ppl making pretty substantial amounts more than that).
It’s back to back so there’s no travel time.
I pay for some no shows and give some sick/vacation days.
People still complain about the rates but they don’t realize the insurance reimbursement rates aren’t all that hot and there are tremendous expenses to run the business.
I am in NJ. Have no idea of the reimbursement rates in NY.
But I know that often I have to lay out or borrow money to pay the payroll as insurance takes so long to pay….
If you can, I advise just working for yourself so you don’t have all this overhead. Don’t take insurance. And you can make $100,000 or so working part time. That would be my advice.
BUT I am just a small speech agency…
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amother
Oatmeal
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Sun, Jan 01 2023, 11:11 pm
I'd suggest speaking to a medical biller. There very knowledgeable about reimbursement rates, in network v out of network, how long reimbursement takes, etc. You have to factor in the cost of billing insurance companies as well, either through paying for software or paying a medical biller.
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momsml
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Wed, Feb 28 2024, 10:02 am
amother Goldenrod wrote: | As an agency owner, I pay $75 and up (depending on experience…ppl making pretty substantial amounts more than that).
It’s back to back so there’s no travel time.
I pay for some no shows and give some sick/vacation days.
People still complain about the rates but they don’t realize the insurance reimbursement rates aren’t all that hot and there are tremendous expenses to run the business.
I am in NJ. Have no idea of the reimbursement rates in NY.
But I know that often I have to lay out or borrow money to pay the payroll as insurance takes so long to pay….
If you can, I advise just working for yourself so you don’t have all this overhead. Don’t take insurance. And you can make $100,000 or so working part time. That would be my advice.
BUT I am just a small speech agency… |
Hi,
I’m just starting out with providing speech services in a NJ clinic. I am not a therapist, just hiring therapists to provide the services in my center. Would you be able to share some info on the general medical necessity and billing parameters?
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