Question 1

How low is “too low” for reimbursement?

Accepted Answer

There’s no universal dollar amount, but you want to compare each payer’s rates to your cost per visit and to benchmarks like Medicare and your commercial contracts. National analyses show that some payers, particularly in behavioral health, reimburse well below the cost of care — one report estimated inpatient behavioral health services were paid at an average of about one‑third under cost. If your own math shows that a contract regularly pays below your fully loaded cost per hour, and there’s no strategic benefit, it’s likely too low.

Question 2

Isn’t it unethical to drop low‑paying insurance when patients depend on it?

Accepted Answer

It’s ethically complex, but unsustainable reimbursement can also be unethical if it leads to burnout, closure, or unsafe caseloads. Studies show that when financial pressure rises, clinicians often reduce access to low‑paying coverage anyway, such as by tightening Medicaid panels. A transparent, planned withdrawal with transitional support can be more responsible than silently eroding access or quality. You can also use your data to support policy efforts to improve reimbursement and reduce administrative burdens that disproportionately harm mental health practices.

Question 3

How often should I review my payer mix?

Accepted Answer

Many small practices look at payer mix only once a year, but revenue‑cycle experts now encourage more frequent monitoring because mix can shift month to month. Quarterly reviews of revenue by payer, average reimbursement per visit, denials, and days in A/R are a reasonable minimum, with a deeper dive annually or before any major contract decision.

Question 4

What if I’m scared to fire a payer because they represent a lot of my patients?

Accepted Answer

Fear is natural, especially if a payer covers a large portion of your panel. However, national data show that coverage churn and plan changes are common, and some patients do end up switching plans or returning to previous insurers over time. Before you make a decision, model scenarios: what if you gradually close to new patients for that plan, or limit certain services, before fully terminating? An incremental approach can soften the landing while you build up other payer relationships or self‑pay offerings.

Question 5

Should I always try to renegotiate before terminating?

Accepted Answer

Yes. Contract‑optimization frameworks emphasize running “what‑if” scenarios and approaching payers with data before deciding to terminate. Show them your local role, access data, and financial realities. Some payers will adjust; some won’t. If they refuse to move and your numbers are untenable, then you’re not “emotional” — you’re making a data‑driven decision.

Question 6

How do administrative burdens factor into the decision?

Accepted Answer

Administrative friction is not just an annoyance — it has measurable financial and workforce effects. Behavioral health providers spend more time and money per transaction on eligibility checks and prior auth than generalists, with estimates of around 24–25 minutes and notable per‑transaction costs when done manually. Nationally, billions are spent on prior auth and denial work, and some payers increase denials and slow payments year over year. If one payer creates a disproportionate share of that burden in your practice, that should weigh heavily in your decision.

Question 7

Can firing a payer actually improve patient care?

Accepted Answer

Counterintuitive as it sounds, yes — if it frees up margin and mental bandwidth. When practices improve their payer mix, case examples show better financial stability and capacity to invest in staff, technology, and expanded services. For mental health specifically, reducing administrative chaos and low‑paying volume can mean more time for supervision, consultation, and clinically appropriate session lengths instead of rushing to make the numbers work.

Question 8

How do I start insurance contract negotiation without damaging the relationship?

Accepted Answer

Start with objective data, not frustration. Gather your reimbursement rates compared to Medicare and your other commercial payers, along with denial rates, days in A/R, and estimated administrative time. Approach provider relations with a clear, professional request that outlines the gap and proposes specific adjustments. Negotiation is less about confrontation and more about testing whether the payer will operate in good faith.

Question 9

What should I use as my minimum acceptable reimbursement rate?

Accepted Answer

Your floor should be your fully loaded cost per session — clinical time, administrative work, overhead, and benefits — plus margin for sustainability. Medicare rates can serve as a transparent baseline, but if a commercial payer reimburses below your cost or below Medicare, that is often a signal the contract is structurally unsustainable.

Posts Tagged ‘billing’

Insurance Contract Negotiation for Therapists: When to Walk Away

Why Insurance Credentialing Failures Stop Payment for Clinicians

Insurance Credentialing Pitfalls That Cost Therapists Thousands

99050 vs 99051 CPT Code: After-Hours Billing for Behavioral Health

90839 & 90840 CPT Codes Explained: How to Bill Crisis Therapy Sessions

CPT Code 96127: Billing Guide for Mental Health Reimbursement (2025)

What Out-of-Network Providers Need to Know About Insurance

Recent DSM-5-TR Updates

6 Reasons Why You Should Avoid Medical Transcribing Services

CMS-1500 Claim Form Guide: Accurate Billing for Behavioral Health Providers

Putting Together a Good Faith Estimate

Complete Guide to Mental Health & Behavioral Health Billing

How to Read Mental Health Eligibility Verification Data

How to get on an Insurance Panel for Mental Health: Step-by-Step Guide

Mental Health Billing Tips for 2022