How to Establish a Private Practice, Part 3: Insurance Panels

Once you've made decisions about when and where to start your practice, it's time to think about how you're going to get paid.

Some therapists choose not to join insurance panels. Some only accept self-pay clients, with or without a sliding scale. This saves them the hassle of negotiating with insurance companies, but it does have a down-side. It tends to require more marketing, banks on a well-established reputation for excellence, and narrows one's clientele. It also seems likely that, with the Affordable Healthcare Act increasing the availability of health insurance, most people will be buying insurance, and therefore likely want to use that insurance to pay for treatment whenever possible.

There are some alternatives when therapists do not want to join panels. Some require clients to pay them directly for services, but give clients a receipt which they can submit to their insurer for reimbursement. Others will accept insurance that includes an "Out of Network" benefit, allowing members to see any provider they choose, with a higher copay for providers who are not on the insurance panel. Usually, the provider has to get authorization and submit claims in a similar way to how "In Network" providers do. However, they do not get the benefit of receiving referrals from the insurance company.

Given that there is a similar amount of paperwork, but less opportunity to receive new referrals when not on panels, therapists wanting to open a private practice should seriously consider seeking admission to insurance panels (in other words, apply to become a provider for health insurers in your area).

Where does one even begin? Well, a logical starting point is to make a list of all the insurance companies operating in your area. Your professional association may already have made a list, so check their website. Other professionals in the area can also be a resource in identifying available panels.

Next, look at the list and determine whether you already have a relationship with any of the insurers. Sometimes clinicians are providers on insurance panels through their agency work, and can transfer their provider relationship to an independent practice. Also consider which panels you are - and are not - interested in joining. Insurers vary in reimbursement rates, and quality of provider relations. For example, one of the major companies in my area tries to interfere so much in dictating interventions for clients they've never actually met that I just don't want to work with them.

Once you have your "short list" of panels you would like to join, you have a choice in how to proceed: you can hire a billing or credentialing company to do a lot of the legwork for you, or you can go through the process yourself. Money is obviously a factor here - one quote I heard for a company to help with credentialing was $200 per panel! In general, it doesn't seem necessary to me, since the application is not that onerous. That said, however, there are some panels that say they're closed, and you pretty much have to know somebody to get on them; in those cases, credentialing services may be worth it.

If you decide to see how far you can get on your own before investing extra money in your start-up, begin by going to the insurance companies' websites. Click on the "providers" section, and look for something about becoming a provider or joining the panel. Depending on where you will be practicing, some panels may be closed (typically because they feel they have enough providers, though sometimes an "insider" can still help you get in - see above), while others will outline a process for applying.

The process does differ from company to company, but typically involves the following steps:

1) Filling out an application

For the application, you will need to be licensed, have an NPI number, a tax payer identification number (for an individual provider, this can be your social security number), a practice address (where you will actually see clients), and a billing address if it is different (e.g., I use my home address; others may use a billing company). You may need a copy of your license or diploma, and a copy of your professional liability insurance face sheet. You may also be asked to furnish proof of your landlord's building liability insurance (usually that policy's face sheet - yes, really).

You will probably have to identify a clinician already on that insurer's panel who will cover for you if there is an emergency when you are on vacation or otherwise unavailable. You may need his/her NPI number. You may also have to identify a psychopharmacologist on that insurer's panel to whom you will refer if medication is necessary. You may also need to provide reference letters from clinicians who are on the panel. It pays to develop a professional network, and find out who is on various panels. When in doubt, most insurers have a provider search feature on their websites, and you can search or browse for providers you may know.

You will also be asked to indicate what populations you serve, what problems you treat, and what interventions you use. To substantiate your expertise, you may have to provide a 5 or 10 year work history, or some form of documentation showing expertise with a special population (eating disorders, or trauma, for example).

There will probably be some form of declaration or attestation to sign, along with a W-9 form (for reimbursement). Once you have all the information and documents complete, you will either fax or mail them to the address listed on the application.

2) The CAQH Universal Provider Datasource

Either before or after submitting the application, you will be asked to complete the credentialing process through the CAQH Universal Provider Datasource. This is an online clearinghouse that gathers information and documents from healthcare providers, to be accessed by insurance companies or healthcare organizations seeking to credential individual providers. You will have to get an ID number for CAQH from one of the insurance companies to which you are applying. Some allow you to call them to get this number; for others, you will get it after you have sent in your application.

Once you have an ID number, you can go to the website and create a username and password. Then, you begin the process of entering information. Bear in mind that this website is used for all kinds of healthcare providers, so you will not have responses to every question. You will need all of the same information you needed for the application: practice and billing addresses, NPI and license numbers, any professional memberships, work history, specialties, etc.

The application gives you the option of either selecting specific insurers to whom you want your information to be available, or making your information available to any insurer that attests you have applied for credentialing. I chose the latter, so as to avoid being turned down if I don't list the correct insurer; other people may be more concerned about privacy and choose the former option.

After completing the online application, you will be asked to review and attest to your responses (and you will have to reattest every 4 months). It will then prompt you to print a personalized fax cover sheet, with which to fax in copies of supporting documentation. There is a signature page that will also print, and is one of the required attachments, along with a copy of your license. Other documents you should submit include your liability insurance face sheet, a W-9, a copy of your CV, and reference letters if you have them. It will take 2-3 days for these documents to be added to your CAQH application, at which point it will be complete.

3) The contract

If the insurance company is interested, they will send you a packet with copies of a contract for you to read, sign and return to them. They then check any remaining documentation (e.g., CAQH if they have not yet reviewed it), and if all goes well, sign and return a copy to you with a welcome letter and effective date, outlining when you can start accepting their insurance, and which of their products you can accept (e.g., many have HMO, PPO, and Medicare plans, but you might not contract with all of them). Once you get this letter, you become an "In Network Provider" and can begin seeing clients using this insurance. You will also be listed on their provider list, which can be a source of additional referrals.

Why Young Home Owners Need a Medicine Hat Home Insurance Policy

As a young homeowner in Medicine Hat, it is sometimes easy to neglect the importance of home insurance coverage.

The truth is that this type of coverage is absolutely necessary to the well-being of your family. Not only does it have the potential to save you tons of trouble down the road -- it even has the potential to prevent you from going bankrupt. Now you might think that "going bankrupt" will never happen to you. While it is certainly unlikely to happen, as long as the possibility remains you should never overlook it.

You see, losing your home to a fire or experiencing your first break-in are all very real, possible scenarios. Just because you are a young homeowner does not mean that you are immune to disasters. It is your responsibility, therefore, to do everything in your power to prevent such disasters from striking your home and your family.

It is also your responsibility to make sure that your back is covered if you are unable to completely prevent such disasters.

For you and many others, this is when a home insurance policy comes into play. Since many types of home insurance policies can be found out there, we recommend that you discuss with your insurance broker which one(s) would benefit you the most. Until then, you might enjoy doing a bit of research on your own. If you are feeling like it, you might even like to request a free Medicine Hat home insurance quote such as the one Sharp Insurance offers.

Test Your Well Water!

Well Water: Safe or Unsafe?

People are very proud of their well water.  When you hear someone say, "we're on well water", the pride and maybe slight pity for people on city water is evident in their facial expression and the lack of need to say more.  I almost never hear people go on about their water--about test results, about the way it tastes. Just simply "We're on well water," with a smile, as if that answers all my questions about their health.

Over the years, I have asked people to test their well water because they were having unanswerable health problems.  The tests revealed elevated levels of arsenic, sulphur, iron, aluminum, copper, and lead.  These can all lead to health problems. Arsenic can cause eczema and cancer, sulphur can cause skin irritation and rectal itching, iron can accumulate in the liver causing multiple deleterious effects including liver failure, aluminum is associated with Alzheimers and other neurological issues, copper causes neurological issues and displaces zinc, lead can cause low IQ in children, other neurodevelopmental problems, stunted growth, fatigue and brain fog.

One patient came to me with many neurological symptoms and exhaustion.  Although her diagnoses were many, one of them was lyme disease.  They live on acreage and she sees ticks around all the time.  She went to a lyme specialist for 3 years with little positive effect on her symptoms.  She returned to our clinic to deal with other diagnoses, as the lyme treatments had been exhausted.  During the three years she had been gone, she had been experiencing serious brain fog and muscle contractions which almost seemed seizure like at night in bed. Her arms would contract up and her hands would go into fists while her legs had charley horses and her face contorted into twitches and grimaces.  When she came back to me, I asked her to get her well water checked.  She didn't want to because she thought the well water had not changed since they had it tested 4 years prior.  I asked her to send me the old results but advised on getting new ones.

The results astounded me.  The well was contaminated with three metals.  Aluminum and lead were in the elevated range and copper was above the EPA critical amount.  There was even a warning with an exclamation point on the test result showing that the copper level was unacceptable for human consumption.  Yet she had been drinking this water the entire four years since the test and for many years before that! The only time she had felt better during her lyme treatment was when she moved to Seattle to do 3 months of hyperbaric oxygen treatments.  Obviously, she was not drinking her well water during this time. Copper toxicity causes brain fog, muscle cramps, facial twitches and grimaces and seizure like contractions of the upper limbs specifically with the thumbs contracted in and hands clenched in a fist.  Clearly lyme disease was not the only source of her neurological problems.

Even if you do not use chemicals on your land, the heavy metals could be in your aquifer from a prior resident, nearby manufacturing plant, or a close neighboring farm.

Here is how contaminants get into your well water.  The above picture is only showing a few sources of contamination on the average farm.  Bacteria and pharmaceuticals can come from septic, bacteria from livestock, diesel fuel used to leak lead but now still can leak sulphur into the water table. Because of environmental laws, lead was removed in 1995. Diesel fuel still has elevated sulphur which new laws have been enacted to reduce.

In addition, fungicides, herbicides, and pesticides can make it in to the water table and therefore the private well.  Copper is used as a fungicide on many crops including grains, apples, peaches, blueberries, raspberries and many others. It also reduces algae formation, so it is used directly on standing water sources such as ponds.  However, household water copper contamination usually comes from deteriorating copper pipes.  Any home that has copper piping throughout can have copper contamination in the water, especially if the pH of the water is acidic (below pH of 7).  In fact, this patient's water was very acidic at 5.4 pH.  The water test had that noted as well.  I do not know where the water was drawn from for the water test. If it was drawn from the indoor taps, the copper could be coming from pipes. If it was drawn directly from the well, then the patient's copper consumption can be much higher than the well water test suggests, if they have copper piping.

Normally, the required tests for well water only check for bacteria.  Many times you have to ask for your well water to be checked for minerals and heavy metals or you will never know your well is contaminated. Most counties offer an extended water test panel for an additional $100-$200 above the normal bacteria count test.  It is definitely worth it. Test your well water!

Best Gluten Free Oat Waffle recipe

Last night at Chucks Produce an enticing aroma filled the education kitchen and drifted through the cracks in the doorway, into the produce section and met the stacks of red ripe local strawberries:  Fresh baked waffles!  The lucky few who came (as well as a few who came for the class that met right after) got to have hot waffles with ripe local strawberries and homemade whipped cream. Best of all--the waffles were gluten free!

I love this waffles recipe because it is simple: no tapioca flour, no xanthan gum, no potato starch.  Just oat flour. I like oats because they are high in fiber, high in silica (feeds the bones, hair, skin and nails), and it's easy on the GI tract.  These waffles taste great--most people like them better than regular waffles!

To get a truly authentic waffle texture (not grainy, fluffy) use Bob's Red Mill oat flour and buttermilk.  Bob's Red Mill oat flour is finely ground.  HOWEVER, the Bob's oat flour is NOT guaranteed gluten free. It is made from regular oats in the regular facility.  To make completely gluten free oat flour, simply get the Bob's Red Mill gluten free oats and grind them in a coffee grinder set to the espresso or fine setting. The result will not be as fine as the factory ground oats, but in the waffle recipe, it does not matter.  If you have a Vitamix, you will be able to make a more finely ground flour.

We used almond milk in case there was someone present who could not have dairy. Of course, the whipped cream is dairy, but you could substitute Cool Whip if desired (even though it's not a healthy substitution). In addition the recipe uses honey or maple syrup rather than sugar and coconut oil rather than vegetable oil.  This recipe is a healthy option for breakfast or dessert.  Keep this on hand for a quick dessert when berries are in season.  It only takes about 10 minutes to make a batch of waffles!

Oat Waffle recipe

Preheat waffle iron

1 1/2 cups oat flour
1 tablespoon baking powder (aluminum free is recommended)
1/8 tsp salt
3 heaping tablespoons ground flax seeds (this is optional, but gives more fiber and essential fatty acids to the recipe)

Mix the above dry ingredients in a medium sized mixing bowl. Then add:

1 cup milk (buttermilk or almond milk or other milk substitute)
2 eggs
2 tablespoons coconut oil, melted
2 tablespoons honey or real maple syrup

Mix batter until well incorporated. Don't worry about overmixing. It doesn't matter in a waffle recipe.  Pour into waffle iron (don't overfill).  Wait until steam has subsided, that is when waffles are done.

Top with freshly sliced ripe strawberries, blueberries, raspberries and top with whipped cream.  Yum!