March 2, 2007

Medicaid pays Licensed Professional Counselors $52.51 per session for therapy, at least here in Texas. It’s an amount that has started to haunt me.

When I was re-entering the private practice world as a therapist, $52.51 per session seemed reasonable. Working with a group practice in an office setting, I could expect to earn about 50% of the money I generated. With managed care companies paying anywhere from $50 to $65 or so per session I was looking at earning about $25 to $33 per session. A full session lasts a minimum of 45 face-to-face minutes, and shouldn’t go more than 50 minutes unless there’s an urgent need. Add the prep time with reviewing notes and treatment plans, add charting time, add a little time for filling out paperwork to get paid, and I’d be lucky to finish all the work for one session in one and a half hours.

$30 for one and a half hours is $20 per hour. Since it’s contract work I would pay self-employment tax, making it comparable to $18.50 per hour. And there are no benefits of any kind: no paid holidays, no sick days, no insurance coverage, no nothin’.

Working with children in foster care, I was going to be paid all of the $52.51 per session. I wouldn’t have to pay any percentage to use an office, but I would have to pay my own overhead. Sessions take place in the children’s schools or homes, so there is no office rent. I needed my home office, which was already set up. The main trade-off for not having office space was the driving time. I was hoping the total drive time per session would be 45 minutes to one hour. There are caseworkers and foster care case managers to talk with, plus foster parents and school personnel, so I expected to have more writing, e-mailing, and talking on the phone for each session than in a traditional office practice, too. I was thinking I could spend two and a half hours per session. I figured it would generate $20 per hour, with just a little overhead. It sounded reasonable, didn’t it?

My first two clients were in the range of the less-than-an-hour round trip. All the rest were 45 to 55 minutes away, making the round trip one and a half to nearly two hours long. Report requirements were more than I expected. I was doing good to make $15 per hour before paying any overhead and any of the costs of driving. The work was rewarding at times in ways other than money, but not often, and not enough to make it worthwhile. My experiment was over by September. I accepted no new clients and finished treatment with all but one. A new therapist was finally chosen to replace me, and I had my final session this January.

And then the $52.51 started haunting me. First, Medicaid put a hold on paying me for my one session in December. They thought it was over the total number of sessions allowed, but I had prior authorization. They said I would have to wait until it was denied and then appeal with the authorization information. After about nine weeks, I finally got the denial, and found out they had ADJUSTED the claim on my seven previous sessions with that client. They were saying I owed them $367.57. I had authorization for all seven sessions, but I had not completed the claims properly.

After nearly an hour on the phone going through each 24-digit claim number and providing the appropriate 10-digit authorization number for each one, I was told the claims would be re-evaluated. I do not know when, nor how much more I may have to do in order to get it, but I WILL GET MY $52.51!

Therapists are being pushed to get National Provider Identifier numbers, and many managed care companies will be requiring them. Managed care is also transitioning to on-line submission of claims and client information. Therapists have been able to avoid the complicated requirements of HIPAA (health care records-keeping guidelines) by avoiding internet-based transactions and records. With the NPI and the trend to electronic filing, therapists will be required to comply with all the standards of HIPAA, even in small solo practices. It’s going to be an added expense and a regular, dull headache.

It’s good to be gone.

May You Find Your Tribe and Join Their Song,

Steve Coxsey


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