#141 Therapy Credentialing and Billing 101 with Kara Welke

In talking to therapy start-ups this year, I've heard a common stumbling block: Credentialing.

And, honestly, I was shocked when I dug into the space. It feels like the seemingly boring task of getting credentialed with insurance has turned into what honestly feels like a world of sharks. It seems like there are 3 trends at play:

This is truly a bureaucratic headache: You do need to buckle up for some super confusing portals to get credentialed.

Credentialing services are all too happy to take your money: They take your personal information because of this barrier-but because the process itself is murky, they often over-promise and under-deliver, without clarity into what is happening.

Big companies like Grow Therapy want to present this task as too difficult for an average therapist, so you join their platform (where they do the credentialing for you, but own your contract).

In today's episode, we want you to feel empowered to understand credentialing and billing with insurance. We'll help you understand this complex system and how you can navigate it.

Honestly, every therapist who works in insurance reimbursement should understand this process (because if you don't do it yourself, that means someone is probably doing it on your behalf). Our goal is for you to leave with a checklist of what to do-and the confidence to do it!

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Transcript

SPEAKER_00 0:00

In talking to therapy startups this past year, I have heard a common stumbling block: credentialing. And honestly, when I dug into the credentialing space, it feels like the seemingly boring task of getting credentialed with insurance has turned into what just feels like a world of sharks. It seems like there are three trends at play. One, getting credentialed is truly a bureaucratic headache. You need to buckle up for some super confusing portals to get credentialed. Two, credentialing services are all too happy to take your money. But because the process itself is murky, they often overpromise and underdeliver without clarity into what is happening. And three, big companies like Grow Therapy want to present this task as too difficult for the average therapist so that you join their platform where they do the credentialing for you, but they ultimately own your contract. So in today's episode, we want to help you feel empowered to understand credentialing and billing with insurance. We'll help you understand this complex system and how you can navigate it. Honestly, every therapist who works in insurance reimbursement should understand this process. Because if you aren't doing it yourself, that means that someone is probably doing it on your behalf. Our goal is for you to leave with a checklist of what to do and the confidence to do it. So let's dive in. Welcome to the OT Potential Podcast. I'm your host, Sarah Lyon, OTRL, and I wanted to let you know that this podcast may qualify as continuing education for you. You are probably listening to this podcast on a free podcast platform. But to gain CEU credit, you will need to be a member of the OT Potential Club, our OT Continuing Education platform. You can go to OTPotential.com to learn more. Okay, here we go. Joining us in the studio today is Kara Welkie, OTD OTRL C L T. Kara is the founder of next level occupational therapy and home therapy solutions. Since 2019, she has supported occupational therapy professionals and starting and growing private practices with a focus on compliance, billing, and business systems. She leads a team that partners with clinicians to build sustainable high-quality practices that support both patient outcomes and long-term success. Cara is also a leader in geriatric care and founded Home Therapy Solutions in 2018, which became the first mobile therapy practice recognized as an age-friendly therapy practice advancing community-based models that support aging in the right place and align with the 4Ms framework. So without further ado, I will patch Kara into our live studio. Welcome to OT Potential Kara. It's so great to have you.

SPEAKER_01 2:54

Thank you, Sarah. I'm so excited to be here. And it's a huge honor to be here as well because you do so much for our profession. So thank you. Thank you.

SPEAKER_00 3:03

Oh, same to you. Thank you so much for being here. This is honestly a topic I just don't even really want to cover or talk about because it feels like something that should just happen for us. It feels like a system that should work. I've been thinking today that it feels like this is like a symbol of what is wrong with healthcare, is some of our systems have just become too complicated. They're making it too hard to own a practice. They're creating all these patient access problems, but it is figure outable. Um, therapists, I feel like, just need some more resources, some more knowledge. And that is part of what we are going to provide today. Um, before we get into this frustrating reality, though, let's start on a lighter note, which is just hearing your story. I would love to hear just your entrepreneurship journey overall. And then what made you interested in helping uh fellow therapists with their private practices? Perfect.

SPEAKER_01 4:01

So, yeah, I'm an occupational therapist from South Dakota. Grow up on a farm. My mom always loves to tell a story how I would ride my bike a mile or two miles, door-to-door, selling wrapping paper and paper cars when I was little. And I think I've done like every type of pamper chief, Tupperware, side businesses there is. Um, and once I started doing occupational therapy, starting a business was always in the back of my mind, but having no idea how to do it, I just didn't do it. And when I worked um for the different places, I love starting up new programs, helped start new clinics, in fact, helped start a lot of outpatient in-the-home models and assisted living facilities, but really never thought about going and doing it myself. And then in 2012, I switched from practicing on a regular basis to teaching in an OTA program. And I always say I figured I was a pretty good occupational therapist. Um, but it wasn't until I started teaching that I feel like I became a better occupational therapist because it really took me back to our roots and getting really back into occupation-based. And then I was the fieldwork coordinator. So I saw what was happening when our students went out to field work and they were coming back frustrated because they were like, you're teaching us to do all of this occupation-based therapy, but all we're seeing is Theraband or UVEs or walking and so forth. And that really, again, inspired me to try to bring back occupation back into our profession. So throughout the course of teaching and then working, and then I went back to get my OTD and I did a capstone project where I actually thought about doing my capstone project on starting a business, which I should have. But I did this program where we um active engagement in life in a transitional care unit. And it was there that I really realized that not everyone believes or thinks the same thing that we do. And if I really wanted to provide occupation-based services, starting and doing it myself is gonna be the best option, but still no idea. And a field or a student came to me and wanted to do a field work, uh a non-medical home care company. And I was like, well, you can't do a field work there because they don't have an OT, or we it would have to be like a non-traditional route. And she was like, No, I'm pretty sure they have therapy. And I'm like, I don't think they do, but I reached out to the company and they didn't have therapy, but they were just going through the process of getting credentialed with uh or to become a home health agency through Medicare Part A. And I was like, Oh, that's awesome! I've always wanted to do a part B business and so forth. And we got talking and they had me come in, and it was at that meeting with that um per the owners of that company that I decided to start my own business, and not because of my idea, but I was telling him how they should start doing, you know, part B, not just home health part A, and that we would contract, you know, and I would work for them. And he was like, No, you need to start your own business and do the part B, and then we'll contract you for the part A. So that's how home therapy solutions started. Like I think I met with them like maybe March, April, and ended up starting our business that July.

SPEAKER_00 7:32

Wow, I love hearing people's story, and so often uh they are different than what my expectation is. Like, I just think of you as someone who like lives and breathes therapy business and would have thought you had like a business plan drafted as soon as you got out of school and went into it. But I love hearing just the learning process and kind of the unfolding um that happened. I know you started that business. How did you then start helping other therapists? Did that go hand in hand?

SPEAKER_01 8:03

Well, so that kind of plays into it because when I was starting my business, I had no idea what I was doing. But I was also frugal enough that I'm not gonna pay anyone to help me because why would I do that? I'm gonna figure it out on my own. But then when it started getting frustrated and I wasn't getting the answers because I was relying on social media, which again, I definitely recommend not doing, I just tried to wing it and I made so many costly mistakes. Like I don't even want to go on air on all the costly mistakes I made, but I have shared them over time. And it wasn't so I started in July, and then it wasn't until the following April when I was attending um AOTA conference. And actually, since I was a faculty and academic fieldwork coordinator, I always went to the meetings beforehand. And I went up when they were the new president um and the outgoing president were talking and they were talking about how OT, the way of our future, is entrepreneurship. And I was like, 100% agree, but what are you guys doing to help us? Because APTA has a ton of stuff out there, but I couldn't find anything at that time for OT help, you know, and they recommended that I go to a business conference. Well, I'm like, well, that's not much help. Well, I was talking to a friend and he said, Hey, I saw this PT conference, and he's like, You should check it out. So I ended up going to a PT conference, and I got so motivated and excited because I'm like, I want this for OT. So I went to that conference and started next level occupational therapy that weekend. And then we did a lot of random things, um, just mostly just a group connecting. And it wasn't until that October when PDPM hit and therapists were starting to lose their jobs. I don't know if you remember back then, but you know, they were starting to cut and therapists were losing their jobs. And I'm like, well, we can help therapists start their own business. So I reached out to Steve Guk, he's the CEO of Hello Note. I'm like, we should help therapists start their business because a lot, so many people are losing their jobs. So that's when our therapy business builder program started. Now, when we started, we just helped people get everything going to get their business set up. Um, we it's nothing like what we do now, but that's how it came to be. And then over the course of time, our program has grown um based on the needs of therapists, based on what you know we've gone through and what our other coaches have gone through. So we can help minimize therapists going through those struggles and um make things easier and save them time, money, and stress in the long run.

SPEAKER_00 10:50

Uh, I love how your story is like totally setting the tone for this conversation on credentialing, because we're going to be talking so much about like doing the next step and just figuring out the next step. And I love how that is how you have operated, it sounds like throughout your whole career, like one thing at a time, and you can figure it out. Um, as we look at this issue of credentialing, um, it just honestly came on my radar in like the last six months as I've been talking to friends who have been launching their businesses. I've been so surprised how often credentialing has come up for them. One, I've heard stories of um like hiring a service and it just being a nightmare, then hiring another service and it's a nightmare. And finally, I heard uh Christopher Gaskins, I think he said it here on the podcast, he was like, and finally I just talked to Kara Welkie and um she helped me learn how to do it on my own. What have you learned over the years and just seen over the years as far as credentialing just being this barrier that therapists are hitting? What has that looked like and what's been your experience with that?

SPEAKER_01 12:05

So if you would have asked me back in 2019 when we started our business, I would have said, you shouldn't learn credentialing. It's too much time, effort, let someone else do it for you. Because when we started our program, we helped people set up their businesses so it they were structured the right way. We did their Medicare credentialing. Um, if they did wanted credentialing with other insurances, we helped them quickly learned that that was not the right approach. I mean, we literally created learn helplessness. And I learned that in my own practice because I had no idea what I was doing. And instead of um, I was thinking about this last night when I was thinking about this topic. I can still remember sitting in a Burger King in East Grand Forks, Minnesota, trying to help a therapist I hired do Medicare credentialing. And I got so frustrated, I just reached out to a colleague and was like, Can you just do it for me? So I never learned. And then once you add on another therapist, you have no idea how to do it. And now, two nights ago, I added a new therapist and it took me 18 minutes, and that was still too long for me. But I brain, I blame brain fog since we've had a lot going on lately. So again, our whole mindset, our whole mindset has shifted because when people, when it's done for people, you're not learning and you're not understanding the process. So then when you have to add a new change your address or add a new staff, you have no idea what to do. Plus, you end up having to give all of this information, anyways. You might as well just plug it in to the system and get the credentialing done versus give all this information to someone else. So our mindset has really shifted over the years. So anyone that knew me back in 2019, 2020, you're probably like, Well, you just did it for us. Well, yeah, because we've learned from our mistakes and we've learned from helping so many therapists that if we can help them learn the process, they feel so much more confident. And then they learn a lot of important foundations of their business.

SPEAKER_00 14:17

I just didn't realize so much about credentialing, literally until like the last month of my life. Like I didn't realize how much maintenance goes into it, how when I was working in other settings, someone behind the scenes was like getting me credentialed without me even knowing it. Like I just didn't, I didn't understand the process at all. And all this is going to play into why I do think it's a good idea to uh do what you're saying and take the time to learn it, because on the it will impact so many parts of your business and there's so much maintenance, and it's one of those things that's just worth it to learn. But so give us credentialing, just like 101 big picture. Uh, what is it? What's important for us to know about it? Awesome.

SPEAKER_01 15:06

Yeah. So I think, first of all, many of us, I mean, I had no idea what credentialing was, what credentialing meant um when I was in school, when I left school, when I was working for someone else. Even when I first started my business, I can honestly tell you, I really had no idea what credentialing was. I knew that you had to have some arrangement with insurance companies, right? But what's that called, or what's the term? So just really learning the whole process of what credentialing is, and then some basic number or basic um information around it. So, like MPI number, you know, did do you know or did you know before thinking about this how to get access to your MPI or you know, how that even was set up? Did you set up your own MPI or did your company set it up?

SPEAKER_00 16:00

Uh I remember that I needed an NPI. And I don't remember the process of how I got one. Yeah.

SPEAKER_01 16:09

Like honestly, I I have no idea. One, that was yeah, one, that was many years ago. Yes. Two, we find that a lot of therapists really have no idea because the companies they're working for set up the MPI, get it started, and then they don't really know anything about it, you know, and they don't learn that process. So with an MPI, it's your national provider identification number. And, you know, we all, or most of us, have a type one NPI. So sometimes that's really the first step is making sure people know their MPI and what, and that there is a difference between a type one and a type two. And a type two is one that you need to get set up because that's the type two is the one that's assigned to your business or your organization. So I have a type one MPI number that I've had. I don't know how long I've had it. I mean, I assume once I graduated, the company set it up for me. And then when I started my business, I had to set up a type two MPI. Again, I'm thinking back like, I don't even know how I set it up, um, to be honest with you, but I do have a type two MPI. So that would be the first step in the process. But even before that, I just really encourage people to get a deep dive into their business to know if you even need to become credentialed. Because depending on your business model, who you serve, the services you're providing, where you live, what you do, maybe you don't even want to be credentialed with insurances. And it all depends on all of the different things around you. And my business is completely different than the business down the street or the business in the state over. So it has to be unique to you. That's why I caution you guys getting advice off of social media, because it's probably not the best advice geared towards you. So really dig deep into what you want to do and what you want out of your business. Like, for example, if you're working with older adults, there really is, and you're providing skilled and medically necessary services, there's really no way out of not getting credentialed with Medicare at this time because OTPT and SLP are not able to opt out of Medicare and because of the mandatory claim submission process. Now, I know there's a lot that goes beyond that. And you know, there's people trying to do cash with that population and so forth, but that's a whole nother webinar day or talk. But for the most part, if people are providing skilled, medically necessary OT and your target population is geriatrics, you're gonna want to get credential with at least Medicare. And that was one step, one of my first things I had no idea because I saw all of these PTs doing cash-based programs or cash-based therapy. So that's what I was gonna do. And I quickly learned that with my target population, that wasn't the best move. And we also see people like, oh, I have to get credentialed with this insurance or that insurance. That might be the worst move you can make for your business if it's a poor payer, has, you know, a horrible process. You know, there's other things that you can do. You can do out-of-network billing where you don't actually have to be credentialed with the um with them. You know, you could do cash-based with some insurances, provide super bills. So, really step one, deep dive. And then if you are going to get credentialed, you're gonna need to make sure that you know, you know what your MPI number is, you have your MPI type too. And then, like with Medicare, everything needs to match. So we have people that establish their business, and their business name is maybe Home Therapy Solutions LLC. Well, then they went to set up their EIN, but their EIN is Home Therapy Solutions. So now when you do your Medicare credentialing, they're gonna come back and say those two documents don't match. And so that can cause problems. Even commas. Even some people will put a comma on like their business registration, but then you can't put a comma when you're getting your EIN. And so then they'll deny that until those match. So really just taking a little time and having someone go through it with you the first time and getting that video that you can use over and over again, and or the step by step is gonna help you continue to credential other people in your business and then eventually teach someone else to do it for you with that. So I kind of rambled on. Thoughts about what I talked about so far.

SPEAKER_00 20:52

Yeah, let me repeat back what I just heard. Credentialing uh is simply verifying that you are a professional, like your professional identity with a payer. Um, is that a good way to say it? Yep.

SPEAKER_01 21:10

Insurance credentialing basically is the process of becoming approved by an insurance payer. So you can provide services to their members and get reimbursement. Yep.

SPEAKER_00 21:21

That so for credentialing, usually where it starts is with step number one is your NPI number. Um, there's an individual one that's part one, then there's another one that's part two. That's step one. Probably everyone does that, even if you're private pay, it's probably worth it to have an NPI.

SPEAKER_01 21:41

You're gonna have your MPI type one for sure, right? And then your MPI type two, depending on the type of business, there are some people that say you don't need a type two. There are some people that say you do need a type two, and some of the information you need on if you're gonna depends if you're gonna submit claims um or give a client a super bill. That can come into play as well. Yep.

SPEAKER_00 22:03

So then you get your NPI. Step two is probably looking at um Medicare or Medicaid for like first, probably over a commercial insurance. And let's so I want to get credentialed with one or both of those. What do I need to gather for that process? Awesome.

SPEAKER_01 22:30

So if you're working with geriatrics, I highly recommend Medicare, right? Medicaid, let's talk a little bit about Medicaid. So Medicaid is going to be different in every state. And there could be drastic differences. You know, like in North Dakota, we get credentialed with Medicaid because it pays about the same as Medicare. But in some other states, you know, it it they hardly pay anything. So it really depends um on the state if you want to get in network with Medicaid. And then unfortunately, the Medicaid credentialing process is going to be different in every state. Many states, you know, will re some states will require your Medicare credentialing first when you go to get Medicaid. But it's just a step-by-step process that you're going to do for all of them and basic information, your MPI numbers, your EIN, your business information. And it really just is going through and filling out these forms. Um, you have to know your taxonomy number, you know, different details like that. So yeah, I mean, what you use for Medicare, you're going to be able to use for some of these other insurances. With Medicare, before we work with someone to do their credentialing, we want them to have their business set up with their state. We want them to have their EIN number. They need to have their bank account set up. And then they have to have a letter from the bank or a voided check. Um, and there's some stipulations with that. And um then they have their MPI one and two. And then we also have them pull a copy of their licing license form from their state so they can submit that. They need to know, like when they first got licensed in that state, they're gonna enter that in. And then they're also going to need to plug in when they graduated, what college um we usually attach the diploma as well. So we upload the diploma and the verification of licensure. And then um other questions, you know, it's gonna be like how is your business set up? Are you providing services just in the home? Are you providing it with a clinic? You know, those questions are gonna vary depending on everyone. But those documents I went over are are basic documents to get people started.

SPEAKER_00 24:51

Uh, finding my diploma feels like the hardest part of all of that for sure. I just was helping someone and they actually couldn't find their diploma. Yeah, that would be me. Um, so I'm like googling my Nebraska Medicaid credentialing portal and just finding it. And it's the same with Medicare, I assume. Does the Medicare portal have a name?

SPEAKER_01 25:16

So with Medicare, we all have our own administrators that are over different states, like your Macs. And like for us here in North Dakota, it's Noridian. We have Medicare portals that way. But in order to get set up with Medicare, you're gonna use the Medicare, the central system. Um, you'll hear PECOS is where you're gonna go in and go through the Medicare process to get started with that.

SPEAKER_00 25:45

Okay, there are so many acronyms in this process.

SPEAKER_01 25:48

I'm definitely going to try to put together a document just with I was gonna say for people, I'll send you over our abbreviation list so that so you don't have to recreate the wheel that goes over all of these different acronyms because yeah, it's like you'll hear CAQH a lot. And when you get into um private insurances and so forth, they're gonna want you to have CAQH set up, and that is kind of a centralized hub where you store everything so that the insurances can pull from it. So yeah, but Medicare is you know consistent and it's easy for us to teach people how to do it because you know it's it's pretty much the same across the country for what we need to do with that. But Medicaid, again, you just have to go to the Medicaid website, look up how do you apply to be a provider, and they'll walk you through the process. I will say that I'm not a huge fan of North Dakota or Minnesota's Medicaid application process, but if you can get through it and learn the process, then you're gonna be able to add on future therapists and you're gonna be able to make changes as you grow.

SPEAKER_00 26:59

Uh, one question I have in that is do I need to start with Medicare, Medicaid before I move to commercial insurance, assuming I wanted to do multiples. Um, or could you do all three Medicaid Medicare commercial simultaneously? Is there like a flow you would recommend to people?

SPEAKER_01 27:20

It really depends on your practice area and what type of practice you have. So, you know, we have some practices that just focus, you know, maybe on younger adults um or like 20 to 50 age range, and they might only get credentialed with, you know, say a blue cross blue shield, and that's it. Or again, they might not get credentialed at all. And that doesn't mean you can't still submit claims. You could become an out-of-network provider and submit claims as an out-of-network provider. And sometimes that can be a better option for businesses than actually getting credentialed with a business.

unknown 28:02

Okay.

SPEAKER_01 28:03

And that can get confusing too, because when we like if we dig back to an insurance card, right, when we're looking at insurances, say for like a Blue Cross Blue Shield or a Sanford Health or Medica or Humana, any of those, you know, we also need to look at if they're an HMO or if they're a PPO. And if they're an HMO, you know, HMO insurances usually require clients to stay in network and they often need referrals or prior authorizations, and they might not allow out-of-network um providers to see those clients. However, actually, one of the therapists I was working with this morning, I told her that she's going to need to do a training on gap exceptions or single case agreements. If someone has an HMO and they don't have out-of-network benefits, it doesn't mean that there might not be another opportunity to still see the client and bill their insurance. Sometimes we can get what we call a gap exception or a single case agreement. And sometimes it's not always that bad as far as being a payer. If someone has a PPO, those have more flexibility and include out-of-network benefits so that we can um build the insurance through, you know, build the insurance and get paid by the insurance, but the client will probably have a co-payer and co-insurance on top of that. So again, it really takes going back before you just all of a sudden going and get credentialed with all of these, it all goes back to figuring out what is the best process. Once you figure that out, determining what insurances you really want to get credentialed in. Because if you get credentialed with um an insurance that is a poor payer, then all of a sudden now you're going to try to get out of contract with them. And that can be a pain in the butt. So even starting as an out of network provider might be a better way to test the waters.

SPEAKER_00 30:08

You truly have to be so savvy to navigate this world and doing so much math about does the math make sense to get credentialed.

SPEAKER_01 30:20

We have therapists that we go around and around because they're like, I have to get credentialed with it. One therapist, I I love using her as an example because um she she was like, I have to get credentialed with this insurance. And we knew that the fee schedule was awful. And with being a MOLBA practice, she there was really no margin there. And it's it's like we can't compare ourselves to the bigger clinics, the bigger healthcare systems, because they have a lot more services going on, right? And she ended up listening um and not getting in, not going and getting credentialed with them. And it all worked out, and she's doing very well. And now she also helps to educate others that yeah, don't just get so nervous because you're not getting the clients coming in, or they, you know, they say they're not going to see you because you don't accept their insurance, because there are other options, and you can make it work without getting credentialed with some of these insurances, and it can end up turning out, you know, much better for you and your business because you have to be able to make a profit in order to continue to have your private practice.

SPEAKER_00 31:36

One part I have not understood about this whole process as I'm talking to people is at the end of the day, you want to know how much people are gonna pay you. And Medicare, you have to dig a little bit, but you can look up and you can find that information for your location. Medicaid, uh, also not uh you can't Google it, but you can dig and you can find those rates. I'm so curious about uh kind of that next step of like that uh getting credentialed, and then you're looking at um uh contract. Could you like get credentialed and then see the contract and not sign it? Like what does that next step look like? And how do you actually know what the fee schedule is gonna be?

SPEAKER_01 32:21

Yeah, great question. So, yeah, Medicare, you can find that fee schedule, Medicaid, you can find the Medicaid fee schedules. Make sure you go to your own state Medicaid. Yes, it can be a challenge to find it, but you can find those fee schedules. But yeah, most insurance companies, they're not going to share their fee schedule until you go through the process and before you sign the contract. Um, what I did is, you know, when I started, we got credentialed with Medicare and pretty much Medicare right away. We didn't even get credentialed with um Medicaid right away. And then I started with out-of-network billing first for those companies that we could, so I could kind of get an idea of you know what the fee schedule was. And you know, you're not people aren't supposed to share the fee schedules, right? There's a price, is it price fixing or price? There's a certain term out there, how you know you're not supposed to talk and share fee schedules amongst each other. But I mean, practices know, um, have a general idea of what insurances, fee schedules are in your area. Um, so some people know that if you know, say this insurance, I've heard it's really good payer, they might go through the process because they have that idea. Sometimes someone will start as out of network to get a rough idea of what the fee schedules are, and some will just go through the process. And once they get the contract, they'll see what the fee schedule is and they'll try to negotiate it or turn it down.

SPEAKER_00 33:56

So you could be credentialed, you could get credentialed and then not sign the contract. Yep. So you technically wouldn't complete the credentialing process.

SPEAKER_01 34:05

Yes. Okay. Okay. You go through all the paperwork, they send you the fee schedule, and then you say yay or nay as if you want to continue with it.

SPEAKER_00 34:15

And then you have like a sunk cost sense. So like, but it might still be worth it to walk away if the math doesn't math.

SPEAKER_01 34:25

And that's just it. It's you know, it's hard to make blanket recommendations because we're all so different in our business and our area and so forth. But at least for me, if anything's below Medicare fee schedule, I'm like, it's not worth it. However, that might not be the best advice for someone with a clinic type setting that maybe does shorter visits or, you know, it just it's just really hard to say. I mean, that's why it's so important for therapists to understand their KPIs and what their goals are and and all of that before they decide really what insurances they want to get credentialed with. Yeah.

SPEAKER_00 35:04

And I wish all of our Medicaids were like North Dakota Medicaid, where it matched Medicare. I know that's not most of most of us, and that's uh big on our hearts is wanting to take Medicaid, but makes the math difficult.

SPEAKER_01 35:17

And with Medicaid, like say North Dakota Medicaid, it doesn't cover self-care. You know, so then it's like each of these insurances have their own nuances. So having to know and understand those too, once you start getting credentialed without these insurances, then you have to really learn, you know, all the bits and pieces about it. Another thing, like some insurances, um, they limit you to four units a visit. And some people don't realize that until after they've seen a client for so many times and they're wondering why, you know, they're not getting reimbursed what they should, but they didn't read that they only cover four units in a day or things like that.

SPEAKER_00 36:00

That's starting to um get into billing and this overall revenue cycle management process. What do you want people to know about that stage of the cycle? Um, I'm definitely thinking about like your EMR and is it helping you to like recognize those, like those rules that go with different payers? Um, I know that's where our EMRs are going, but yeah, what what do you want people to know about that part of the process?

SPEAKER_01 36:28

Yeah, same thing. I learned the hard way. Many therapists learn the hard way that it's really important just to learn billing and understanding the revenue cycle management process because it's the basis to your whole business, right? And if you don't understand it, you don't know when there are problems. And some people get so stressed out, me included, that you just kind of freak out and hire a billing company. And that was one of the worst things I did, and it's one of the worst things many people do because they don't care as much as you do. And there are many great billing companies out there, so we have relationships with billing companies, and there's great ones, but there's a time and place for it as well. Um, and it's just so important to learn the process. I find that a lot of people expect like their EMR to teach them the process. You know, again, the EMR is the EMR company, they have a tool, they have the EMR system technology to help you do it, but their job is not to teach you how to do it and what all of the different processes are. So I see people EMR hopping a lot because you know it gets frustrating and and it can be time consuming because people don't understand that first you have to get credentialed, then once you get credentialed, you need to set up your clearinghouse. And setting up the clearinghouse can take some time with the EMR. So the EMR can, you know, talk to the clearinghouse, the clearinghouse can talk to the insurance company, and it's a process.

SPEAKER_00 38:07

Can you explain clearinghouse for me?

SPEAKER_01 38:09

Yeah. So I'm again, I'm probably not the best as the official technical words for everything, but how I explain it is your clearinghouse sits between your EMR company and the insurance company. So when I in my EMR, I'm gonna document, do my billing, and I'm gonna click a button and it's gonna send the claim over to the clearinghouse. And the clearinghouse is gonna like scrub it and make sure it has everything that the insurance company meets. And then if it doesn't, it's gonna like say, hey, there's an error, you need to fix this. And then once that's fixed, we're gonna send it over to the insurance company. And then as long as you have things set up appropriately, which a lot of people miss this step, then you in the in the if the process works appropriately, then the insurance companies, once you get paid, it's gonna send the information back to the clearinghouse with what they paid, and then that's gonna cycle back into your EMR. And many EMRs, revenue cycle management programs out there, you know, a lot of them are just a few clicks of the button. For the therapists we work with, we really take them through the steps so they understand the process before we do all the automations because we want them to know what happens and why what does it need to have in the EMR so that when it goes to clearinghouse, it clears that and then what to look for. Like if it comes back with an error denied or whatever, we can help you figure out the process. Because if you just automate it, then everything kind of goes crazy. So I think about like you see, like the um printers printing off everything crazily and it flying all over the office. I'm like, if you send claims through and you have no idea what you're doing, it can just kind of create a mess as well. So we want to people to know and understand how that process all works so that it works seamlessly. And honestly, some people we get to the point where we teach them process and they know and understand it, but they dislike it, they don't want to deal with it, or they have trouble. Then we'll pull in, you know, a billing company that we know and trust to kind of help take it over. Um, but a lot of our therapists with the integrated billing out there and AI coming in and making things a lot easier, a lot of therapists can manage it themselves and keep it in-house. And that's a huge cost savings as well.

SPEAKER_00 40:40

I want to ask two quick timeline questions. One is going back to the beginning and uh the credentialing process. Say I'm uh trying to get credentialed with Medicare. What's a reasonable timeline to have in my mind? And then I also want to know the timeline um in this billing process of I see the patient, it goes clearing house, insurance, clearinghouse back to me. What's that timeline?

SPEAKER_01 41:04

Yeah, so it's gonna vary depending on the insurances and what's going on in the chaotic world, right? Um, with Medicare, you know, sometimes we when we um what we usually do when we work with people is we help them go through and learn the process. And then um then from there, they're able to take it and go from there. So some people they get credentialed within a month, some take a couple months. It can depend on area of the country, the max that you're dealing with. Um, if there's some mistakes, they'll usually send it back. You can fix it, they'll send it over. Other times we have people coming to us that have been trying to do it on their own, and then there's errors or issues, and that's when it can drag on for multiple months and cause, you know, a lot of problems. And sometimes there's issues. We had um one of our therapists we work with. Um this is just crazy, but Medicare was paying or the claim for going to another provider and not hers. Nothing is nothing she did. So sometimes there's issues that that do come on, but a lot of times it can be a pretty seamless process where we say, you know, I think technically a lot of places say 45 to 90 days, but we see it happening um, you know, around a month or even less to get Medicare credentialing up and going, but that's not guaranteed. So don't take my word. Yeah. Um, because a lot of things go into it and everything has to be um done correctly with that, but it's not as it's not as bad as a lot of people think. Once you get credentialed, um, then you need to um work with your EMR company to get the clearinghouse set up. And a lot of EMR companies will help, you know, go through that process. And you know, they usually say that can take 45 plus days. Again, um, a biller or an EMR company might give you different timelines depending on their systems. But I try to tell therapists that you need to think about it's gonna take time with credentialing, it's gonna take time to get the clearinghouse set up because yeah, once you're approved with credentialing, you can see a client, but you can't submit that claim until those things are set up. So we have had people that, you know, they did credentialing, but they didn't think about the timeline for the clearinghouse and they've started seeing clients. Well, they're not able to get paid. And then that can create some financial hardships as well until everything's set up and it's processing smoothly.

SPEAKER_00 43:42

And what about that timeline? Of I saw the patient, it bounced from the clearing health insurer and back.

SPEAKER_01 43:48

Once everything's set up and functioning, like Medicare is around 14 days. Um, other insurances can take longer. You know, if they're if people have a Medigap plan, Medicare. Usually forwards it to that plan, and that's going to take a little bit longer. And then again, another thing that people often don't realize is say you're seeing someone on Medicare and they have a Medigap plan, or like say they have Blue Cross Blue Shield. So Medicare will, if it's on file that they have the Medigap plan, Medicare will often just forward it to like say the Blue Cross Blue Shield. But you have to register, not get credentialed. You have to register with Blue Cross Blue Shield before they will pay you because they have to keep track for their business purposes. So they're not going to send you, you know, $200 until they have, you know, like your um information on file so they can give you a 1099 at the end of the year. Some people get confused and think they actually have to credential with them. That's not the case. You have to go through and register so they have your information that so they can submit your payment. So that can take a little more time initially until you get those things set up.

SPEAKER_00 45:07

This is all feeling like it's figure outable, but you got to buckle up for some work and an amount of time. Um, once you get up and going, I want to ask a little bit about maintenance. I had a specific question in the comment about adding other OTs or PTs to your credential business. I want to ask you that. And then I just want to ask um big picture with maintenance. I'm curious, just a mindset, like setting your mindset for what percentage of your time might be spent on um this RC, like the overall RCM process. Like, I think I heard someone say they set a aside their Friday, they have multiple therapists, but I'm like, I see how this could take a whole day of the week. What's a good mindset for maintenance of this whole cycle?

SPEAKER_01 45:59

Yeah, so our goal or our recommendation, and this can vary by anyone, but when someone's coming in, we're really working on helping them establish that solid foundation so they have their credentialing set up, they understand, they have the records of who they're credentialed with, what their rules and regulations are, and then they know and understand the process for adding therapists. They learn the billing cycle, so they know and understand the billing cycle. Um, they start seeing clients. But again, there's gonna get to be a time when it's not appropriate for me to be spending my time doing all of this when I could be making more money going to see a client, right? So there is gonna be a time then maybe you bring an admin in or a virtual assistant, maybe you do a billing company. Um, again, it all goes back to we really are looking at your KPIs, your goals, your financials, what you want to do. But an admin might be someone that somebody brings in first to carry out the credentialing and the billing process. So then that frees up your time to go see clients, market, and do higher level things. I love the book, Buy Back Your Time. I'd highly recommend that because I think a lot of us really undervalue our time. And if we can really dig in and learn this process, know and understand it and have a good handle, which I wish I did in my business back in the day, um, it's gonna set you up for a lot smoother process as you go forward and bringing in other staff to help you do it. So it's not that I'm advocating you do it all the time, but when you're first getting started, you know, yeah, at least once a week, submit your billing, reconcile your claims, um, making sure everything's good. We want you to follow up if there's issues, then you start doing it more often. And again, a lot of these systems, it's automated. So you, you know, it'll just submit the claims and reconcile it for you on a regular basis. But pull your reports, pull your reports to see how many claims went out, who paid, who didn't. It's really interesting when we meet with therapy companies that have been up for a long time and we have them pull reports and they look and they're like, holy cow, like there's 20 sessions on here. I never got paid anything, you know, and it might be something as simple as, well, it's the beginning of the year and the deductible um was there and you just never collected it, or you know, maybe they switched insurance, or unfortunately, maybe they were on home health. Um, so if you can learn it, it's gonna be so much smoother. And then you can train someone else to come on. But it's tough. I mean, I have people that get really frustrated and they're like, I can do it, I'm not gonna learn it. I'm just have someone do it for me. We do get to that process, but overall, for the majority of people, they learn it, understand it, and then bring someone else in to help with it. Or use your systems, your automations with your EMR companies.

unknown 48:58

Yeah.

SPEAKER_00 48:59

Part of the reason it's worth it to learn and understand is this specific question someone asked of um adding more therapists. Seems like you need to get back into your portal, probably, to add get each new therapist at your company credentialed. I remember um, I'm just going to use her name. Alison Stover told me that part of her hiring checklist is she has the therapists get in to the portal themselves and credential. That's what their Medicaid wants. They want the individual therapist to get in there and register. Any advice on getting uh more therapists registered?

SPEAKER_01 49:38

Once people like like I'll talk about Medicare, because again, geriatrics is my passion and what we do and and see the most. And I mean, we are in network with other insurances, but Medicare, once you guys learn the process, it is so quick and easy to add other therapists to it. And it's we have like an orientation list of all the insurances and what we need. And then when you do other private insurances and you use the CAQH, that helps as well. But like Medicare, it really is really quick and easy. Um, I just did two therapists the other night. Um, and again, I don't do a whole lot with my home therapy solutions business anymore, but that's something I can easily just do. So once you know the process, it's not too bad. Now, I will say some of the other systems are a little more pain in the butt. Also, you got to think about and create a spreadsheet. So, whatever insurance you get credentialed with, create a spreadsheet or maybe your ERM or your EMR or your CRM might have, you know, a way to track this, but keep track of your insurances, your portals. Unfortunately, yes, they're a pain in the butt because yeah, you know, they're always changing passwords and have some different things, but you're gonna have to do like revalidations um and keep up on all that. But really, they send the they send the reminders out to you so you can go ahead and do it. And there are, you know, like I just got something from Sanford Health, you know, and our therapist has to go in and and do some of that. So it's not as bad. It's almost worse when you have another company doing it because then it's just going through you can remove that middleman um and just do it yourself or keep it in health.

SPEAKER_00 51:19

One of my friends who's getting credentialed currently, she finally got connected with an actual person for R State Medicaid, too. Um, and that helped her tremendously. Is that common to be able to get to a person?

SPEAKER_01 51:33

So sometimes it's extremely hard to get to a person, but I will tell you with R State Medicaid, I have a gem. Um as well. The person. Let me tell you, I have kept her name and her number and her email so I can call her um when I'm having trouble. So it can be really hard getting through to some of these insurance companies. I've been having a heck of a time with another state's Medicaid, and um finally saw that they have posted they're just way delayed on everything. So yeah, I mean, it can't, it can be difficult. But really, if you get a good system in place, you guys can do it and keep it in-house and train someone to do it.

SPEAKER_00 52:15

I feel like as you're talking about it, it makes it feel like figure-outable and navigatable. I'm like, yes, we can totally do it. But I do want to spend a moment just being like, this is a nuts system.

SPEAKER_01 52:30

Like it's a it's when I was sitting down and answering the questions and thinking about it last night. I'm like, no one's gonna want to do this or start a business. Um, because it does stink, you know. But on the other hand, I will tell you that there's nothing better than having your own private practice, creating a great place for you to hire therapists and give them a quality work environment and providing the services you know that your clients deserve. And yeah, there are people doing cash-based practices, but not everyone can afford cash-based practices, or there's other people that want to use insurances. And again, my population is geriatrics and all and they want to use their insurance. Um, and a lot of the therapy we're providing is skilled and medically necessary. So it is doable and it is worth it. And if you can just get help, it's going to pay off in dividends. Think about when you start and build a business, you need to invest in it. And the more you invest up front, the more it's gonna pay off down the road. I didn't have that mindset when I started. I was gonna do everything myself. I didn't want to invest, I didn't want to pay money. I was very frugal, and it ended up costing me so much down the road. But a lot of people they end up, you know, still trying to do it. And unfortunately, they learn from the mistakes and then have to come back and kind of start the process over.

SPEAKER_00 53:59

If you could change one thing about our system, what would it be?

SPEAKER_01 54:03

Oh, you asked that question, and I'm like, one thing. Um how do I pick one thing? Um let's see. Just simplification. I just don't understand why we're not to the point where there's not a more uniformed system, um, like not an easier system for insurance verifications, um, learning and understanding coverage, you know, everyone having, you know, some of these private insurances, different authorization requirements, you know, just making a more uniform system would be one thing. Obviously, the fee schedule is another whole discussion point, you know, especially for Medicare. Um, when we look at over the course of time how how it's gone down versus up. But it just seems like if we come in and have a better uniformed system or more consistency between payers, it would help a lot. But I have a mile-long list. That's probably for that's probably for a whole week to schedule.

SPEAKER_00 55:12

Oh, yeah, it feels like we know how important therapy is. There's so much lip service paid to therapy in a frontline workers. And part of what we need to be loud about at our state level, at the federal level to insurers is that we need systems that reflect the value that we provide. And that uh unfortunately feels like the work of our generation. Um, the world is moving and changing so fast, our systems are getting outdated. And for some reason, it's our cosmic timing in life where we have to find a way to move these systems forward.

SPEAKER_01 55:52

And if you're just shout out, you're a huge part of helping with this. Like your tool that you've put together, um, looking at like payment and uh CPT codes and where it's gone. Do you know what one I'm talking about from? Yes, yeah, yes, yes, is so important. I mean, on Capitol Hill Day last year, I mean, we utilized your tool and talked to the senators and showed them and and what's going on, but we need all of us to do that. Unfortunately, when we come out of school and if we're just working, we don't really think about what goes on behind the scenes, you know. So a small percentage of us are seeing what's actually going on, you know, and we need really everyone to understand it. Yeah.

SPEAKER_00 56:39

And there is hope there. There's a lot we can do. A lot of it is just making the problems more visible. This has been so great to walk through this process to understand it. I feel like a little more calm than I did at the beginning when I was feeling frustrated. In our final minute, what's your like final thought to someone who is in this process and they are frustrated? What's the takeaway?

SPEAKER_01 57:03

First of all, starting and building a practice is 100% worth it. And right away, when you're getting all of this stuff done, it can be really daunting. But if you invest in getting someone that's invested in teaching you, not someone that's just gonna do it for you, but someone that's invested in teaching you so you can learn and understand it, it's gonna help you dramatically in the long run. And know that a lot of this is the beginning nightmare, right? Once you get it up and going, then it's a lot easier and more smoother sailing. Because when we're working with people on getting like their ERAs and all that set up, sometimes it can see really daunting, but it's like getting it set up, then it should be good to go. So again, please we need more private practices out there. So please don't get discouraged. There is help. The more you can do, learn and understand it, and then you can eventually delegate and get someone to help you with it. I know that wasn't just one thing. Sorry, I'm horrible at that.

SPEAKER_00 58:08

Oh, well, Kara, you have shared so much with us today. I just so appreciate your willingness to just be generous with your knowledge and just all the help that you've given to therapy um private practices over the year. Thank you for uh just your overall work and for sharing about it with us today. Thank you just so much for this conversation.

SPEAKER_01 58:29

Well, thank you. And again, thank you for all you do because you do so much to help us therapy professionals and private practice owners and really help us in the whole advocacy world, too. That I don't think you probably know how many lives you impact as well. So thank you. Well, thank you, Kara.

SPEAKER_00 58:46

It's been awesome. Thank you for joining us on the OT Potential podcast. To earn one hour of AOTA approved continuing education for your time today, you will need to sign in or sign up at otpotential.com. Once you're in the OT Potential Club, you will find a five-questioned post-course quiz connected to this episode. When you pass the quiz with a score of 75% or higher, you will be able to download a PDF certificate that certifies your completion of this course. Okay, I want to thank you for joining us today, and we'll see you next time.