Should You Accept Insurance? The Ultimate Guide for SLPs in Private Practice
Choosing how you structure your billing is a big question for most SLPs in private practice. Should you become an insurance provider or only accept private pay? What do you need to keep in mind while choosing either/or? Here's my guide to help you make this big decision.
As a private practice provider, you have two options for who pays for your services:
The client- through private pay/out of pocket
An insurance company, if you are a provider with them
If you only accept private pay, clients who pay out of pocket will often choose to submit a superbill to their insurance company to try to get some of your service fee reimbursed under OON benefits. They might also choose to pay with their HSA cards and be reimbursed through that account. For more information on HSAs and Speech Therapy, ASHA has a good article here.
Here are 5 things to keep in mind when you're deciding whether or not to accept insurance.
1. What is the competition like in your area?
If your area has sparse competition, you might be successful with just private pay. If there is a lot of competition, however, you might need to take insurance just to be competitive. In my area, there is a surplus of SLPs and clinics, so I made the decision to accept insurance so that I could remain competitive in my local market.
2. What is the demographic makeup of your area?
Beyond the other SLPs in your area, you also have to think about what your ideal client looks like and if they exist in your area. Is there a large percentage of residents who would be willing AND able to pay out of pocket for services? If so, you may not need to accept insurance.
3. How much time are you able to devote to marketing?
In general, you will need to devote more time to marketing if you choose NOT to accept insurance because you will not be listed on the insurance websites as a provider. You will also need to directly connect with other providers like pediatricians and dentists in your area since you will not be in an official referral network with them. It's not impossible, but it does require more time spent marketing and networking than if you are an insurance provider who shows up on in-network provider lists.
4. What requirements do the insurance companies have?
You will need to check with each insurance company about what their requirements are- some have specific paperwork they require for sessions, a specific clearinghouse you need to use, or time requirements for CPT codes (e.g. they require sessions billed under 92507 to be an hour long). Others have hard caps on how many speech therapy sessions they will cover per year (from 10 to 50 or more).
You also need to take into account what CPT and ICD-10 codes are covered by each insurance company. For example, many will not cover "developmental" diagnoses like F80.0. Make a list of the your usual CPT codes (like 92507 and 92522), common ICD-10 diagnosis codes like F80.X, F81.X, or others (here is a helpful list of ICD-10 coding information from ASHA), and be sure to ask about their restrictions.
You can generally find out this information by going to the insurance company's website and clicking on the link for Providers, then either calling the information hotline listed or downloading the provider manual if it is available.
5. What information will you need as an OON provider?
OON= Out of Network. As I mentioned above, when you only accept private pay, many clients will request a superbill that they can submit to their insurance company to see if it is covered under OON benefits. Often, those companies will require further information from you such as your state license info, ASHA number, and sometimes even bank information if you want an EFT (I explain that acronym in this blog post). That's why I recommend having all of your pertinent licensure info + EIN on your superbills/invoices, which is very easy if you use an EHR that automatically creates them.
Hopefully that information was helpful! If you want more information, including a handy comparison chart for insurance vs private pay, it's available in my Private Practice Foundations course- a one-stop guide to starting your private practice.
Have comments or questions that I didn't answer? Comment below!