About Your Billing Buddy

Hello! I’m Susan Frager

I graduated with a Masters in Social Work in 1991. Prior to that, I had been a psychology PhD student, until I realized that research was not my ambition. My career goal was to become a therapist in private practice.

Academia doesn’t prepare us for the business aspects of private practice. You wouldn’t be visiting this page, otherwise. When I obtained my MSW, I was no more prepared for successfully operating a private practice than you were.

In late 1993, I got a “dream” job as an employee assistance therapist. Only two years later, burnt out from scheduling 36 clients per week plus visiting hospitals after hours to try to “divert” patients from admission, I figured I’d do less harm at the corporate headquarters. I performed a variety of clinical care management roles, but while doing so, I became fascinated by just how …toxic… this system was. Not just my employer; the entire US healthcare system.

Every day, I was yelled at, by practitioners and patients frustrated with “the system.” I was powerless to help. As I learned more, an idea came to me: why don’t I start a company helping therapists and psychiatrists, so they could concentrate on what they had trained for – treating patients?

I eventually reached a “sink or swim” point in my career, where I dreaded going to work every day, knowing I would be yelled at by someone. Racking my brains over how I was going to make a living for the next 4 decades, I decided to take a chance on that crazy idea.

Becoming a biller was not the original intent. I started off helping clinicians obtain authorizations. Remember that? If you wanted insurance to cover care for your clients, it was a 3-4 page request “proving” the medical necessity of continued treatment…every 10 visits or so.

Authorization requests quickly became tedious, so I added billing to my repertoire.

Eventually, authorizations were (thankfully) mostly replaced by the current system of random record audits and live clinical reviews of “outlier” care. I was glad to jettison that part of my services and concentrate solely on billing.

For the next 20 years, I watched the private practice challenges come and go. Life is never dull, as a biller.

Electronic billing? (Wow, cool! No more mailing all these pieces of paper?)

HIPAA (Everyone panicked)

The ICD-10, which ended up being like Y2K. (Remember that? The world didn’t end on January 1, 2000, either.)

And more. There were new CPT codes every few years; the constant Medicare fee cutbacks, recission of cutbacks, and then more cutbacks but under different names. The invention of CAQH, which was supposed to “simplify” credentialing, yet somehow managed to make it more complex. Closed insurance panels. Shorter timely filing periods. Fighting to be reimbursed at decent rates (or at all).

Then came the 4-figure deductibles and an ever-increasing portion of a practitioner’s income coming from the patient, even from patients using insurance. The Affordable Care Act. Electronic medical records & patient portals. Audits. The offshoring of insurance customer service and the inability to answer the basic question “how much will my patient owe?” Nonsensical denials have always been a fact of life, but if you can’t talk to someone at the insurance company, how do you fix them?

The challenges are multiplying and never-ending, and the pace has only quickened in the last few years.

In billing, as soon as you think you have something figured out…it changes.

New challenges are constantly emerging. For instance, are you watching income dribble away because insurances now use third parties to pay, companies who want to charge you for electronic funds transfer or pay you by virtual credit card?

Then, in March 2020, came the COVID-19 pandemic. Overnight, everyone adopted telehealth, yet no one in charge could decide on the correct way to bill and reimburse for it. The uncertainty over telehealth continues as the pandemic drags into its third year and not only have “they” not figured out a standard way to bill for it…they’ve added more codes for it. And will they continue to pay for it?

Meanwhile, the current mental health crisis is real. I don’t know a single behavioral health clinician in January 2022 that doesn’t have a two-figure waiting list. You don’t have enough hours in your day to see all the people who need help. You don’t mind working hard…but you would like to be paid fairly, and without games. By choice, I have kept Psych Admin Partners small. I didn’t want to be a full-time manager and CEO; I actually enjoy billing. (I know…I’m diagnosable). But the myriad of changes brought about by COVID led to a second job researching and interpreting. I was as busy as anyone else during 2020 and 2021. Requests for independent consultations mushroomed.

So why not share what I learned? And Your Billing Buddy was born.