DATE: January 05, 2026 at 02:12PM
SOURCE: PsychBilling Coach Billing Blog by Susan Frager
-------------------------------------------------
TITLE: Eliminate reimbursement rate mysteries!
URL: https://psychbillingcoach.com/end-reimbursement-rate-mysteries/
In mental health private practice, reimbursement rate mysteries plague us all:
• The insurance company won’t tell me what their reimbursement rates are until after I’m credentialed and signed the contract! So how do I decide if I want to join?
•
• Many of my clients need to use insurance. If only I could negotiate a reasonable reimbursement rate! I hear stories that some professionals get better rates, but I can’t figure out how!
•
• I can’t find/wasn’t sent a contract with a fee schedule! Or, over the years insurance panels updated my rates. But they don’t send notices of updates anymore. Sometimes they merged with another company and it’s not clear if I’m getting paid what I should be. Can I find out if I’m being underpaid?
•
• I’m a group practice owner. The venture-capital platforms are killing my business because they can pay better and credential much faster. Is the same procedure delivered through a platform really worth so much more than what my group is reimbursed? I can’t even effectively advocate for my group because I don’t have the reimbursement data! I don’t know how much of a raise I can get away with asking for.
•
What if you could discover what insurance pays everyone in your market for the same CPT code?
You can! A law passed at the end of 2020, called the Transparency in Coverage, or Price Transparency law, mandated release of the reimbursement rate mysteries beginning July 1, 2022, in what they call “machine-readable files.”
The government’s idea was that by publicizing the reimbursement rate mysteries, it would somehow enable consumers to compare prices for healthcare services and shop around for the best deal so that market forces could bring down healthcare costs. But the US healthcare system isn’t exactly a free market. If only one hospital in your city is in-network with your insurance, it doesn’t matter if they charge the most for the surgery you need. You’re still going to go there because to go out of network would be much more costly for you, even at a “lower” price.
Regardless, the reimbursement rate mysteries are quietly released every month in order to satisfy the law.
How do I get my hands on reimbursement rate data?!
Naturally, it’s not as simple as just logging onto Availity or another payer portal and downloading it. Oh no. This dataset is estimated to be 500 terabytes to 1 petabyte. To put that into perspective, 1 petabyte of printed data is about 500 billion pages 100 times more pages than all the volumes in the Library of Congress.
CMS offers oh-so-unhelpful directions on obtaining reimbursement data:
Specific technology may be needed to download and read these files given their size and complexity.
The Departments of Health and Human Services, Labor, and the Treasury envision that third-party developers and other entities will download, process, and compile this data, creating more advanced price transparency tools…
How will this help consumers? That remains to be seen. But we can use this data to help ourselves! Because I now have access to this tool. Naturally, there’s a cost. Those “third-party developers and other entities” always have to be paid, in US healthcare.
But that cost might be worth it, many times over.
Insurance won’t reveal rates prior to paneling
Reimbursement rate mysteries are a thing of the past even if insurance payers still want you to believe otherwise.
You don’t have to be currently contracted to obtain reimbursement data. We can do a market analysis to answer the basic question: “What’s the range of rates that Aetna, United, Cigna, BC/BS pays in your zip code?” From there, it’s just math: are these reimbursement rates adequate to sustain you in practice and earn the income you want? If the rates are lower than acceptable, at what point do you draw the line and say no to a contract?
Part of your decision about joining a panel might be to accommodate current clients whose insurance has changed. The rate may not be ideal, but at what level is it decent enough to participate, as long as you’re not overwhelmed by clients with that plan. Wouldn’t it be better to get reimbursement information before dealing with the hassles and delays of credentialing? Common sense (and the law) say yes, even while insurers still stonewall, playing power games.
Negotiating more realistic reimbursement rates
Wouldn’t you love to be able to write this sentence? “Dear Insurance Company: My request for $150 for a 90837 is justified by what you’re already paying at least 50% of the time to other clinicians with my specialty in my zip code, according to the Transparency in Coverage machine-readable files.”
You might find you’re able to!
It’s a bit more complicated than that, of course. You still have to show how your practice is worth inclusion in the top-reimbursed 50% of the network, rather than at the bottom. Need arguments to persuade insurers?
Are you being underpaid?
Insurance plans underpay often. By not having a clear fee schedule telling you what you’re supposed to earn, you’re unable to fight underpayments.
Once you know what you’re supposed to earn, a good billing platform will allow you to enter the insurer’s fee schedule(s) and can generate automated reports showing where you’re being underpaid.
Underpayments may seem too insignificant to challenge until you start adding up what you lose over a year’s time. What if an insurer was underpaying you by $3 per session? That seems too trivial of a battle to fight until you realize that you saw 4 clients of theirs, 4 times a month, for a total of $576 underpayment last year.
The price transparency data often reveals that you’ve been paid varying amounts for the same procedure. Some of these variances can be explained by insurers’ practice of reimbursing the same procedure differently according to whether the policy is HMO, PPO, on or off the ACA Marketplace, a large self-funded employer group, small employer group, etc.
But if the insurer isn’t clearly explaining the differences in the fee schedules, AND giving you the opportunity to identify which clients belong to which fee schedule, what then? Or maybe they’re giving you all the fee schedules, but the documents and terms used are so incomprehensible that you can’t even answer the simple question “How much should I be getting for a 90837?”
Insurers voluntarily release reimbursement data for commercial employer and individual policies only to comply with federal law. They aren’t exactly motivated to be forthcoming about it with you not without considerable effort on your part possibly involving an Executive Badass complaint. Medicare Advantage, Medicaid, and Tricare/VA reimbursement rate mysteries still need to be addressed with reference to the published federal, state, or military fee schedules.
Groups competing with the platforms
Sometimes the data from the machine-readable Transparency in Coverage files shows that even though the venture-capital platform may be paying you $10-25 more than they would if you were contracted in your private practice, the insurance company is paying the venture-capital platform significantly more. Especially if said insurance company is also an investor in the venture-capital platform. (Just a coincidence, I’m sure…)
And as I previously revealed, in that situation your clients may be overpaying while having to satisfy their deductible but little if any of that extra money goes to you.
In a group setting, the strategy is slightly different. It begins with demonstrating to clinicians how working with you provides a more clinically rewarding and ethical practice life to say nothing of also decreasing isolation and potential burnout. Once you can attract -and retain- good clinicians, the next step is a program of measuring client outcomes, to show insurance payers how your group’s quality of care decreases medical expenditures associated with behavioral health conditions. Managed care executives don’t grant rate increases without this information and you have to show them, not just tell them.
It would be more satisfying to engage in a frontal assault and fight for justice: everyone in the same market should be paid the same rate regardless of ownership or size. But current laws forbid unionizing or similar direct advocacy by private practitioners, so I can’t play Norma Rae until or unless that changes. (Professional associations, are you listening?)
Price transparency data that shines light on insurance payer reimbursement rate mysteries is the best tool we have, at the moment, to improve profitability of behavioral health clinicians in 2026.
Ready to get started?
URL: https://psychbillingcoach.com/end-reimbursement-rate-mysteries/
Articles can be found by scrolling down the page at https://psychbillingcoach.com/billing-blog/ under the title "The Billing Blog".
-------------------------------------------------
This robot is unaffiliated with PsychBilling Coach.
Private, vetted email list for mental health professionals: https://www.clinicians-exchange.org
Unofficial Psychology Today Xitter to toot feed at Psych Today Unofficial Bot @PTUnofficialBot
Psychology news and research articles at Psychology News Robot @PTUnofficialBot
NYU Information for Practice puts out 400-500 good quality health-related research posts per week but its too much for many people, so that bot is limited to just subscribers. You can read it or subscribe at @PsychResearchBot
Since 1991 The National Psychologist has focused on keeping practicing psychologists current with news, information and items of interest. Check them out for more free articles, resources, and subscription information: https://www.nationalpsychologist.com
EMAIL DAILY DIGEST OF RSS FEEDS -- SUBSCRIBE: http://subscribe-article-digests.clinicians-exchange.org
READ ONLINE: http://read-the-rss-mega-archive.clinicians-exchange.org
It's primitive... but it works... mostly...
-------------------------------------------------
#psychology #counseling #socialwork #psychotherapy @psychotherapist @psychotherapists @psychology @socialpsych @socialwork @psychiatry #mentalhealth #psychiatry #healthcare #psychotherapist #doctors #psychotherapist #hospital #HIPAA #privacy #BAA #patientrecords #telehealth #medicalbilling #SusanFrager
