Insurance Billing & RCM

If you look strictly at the headline conversion factor, Medicare PT/OT Fee Schedule reimbursement for physical and occupational therapy appears to have received a welcome boost for 2026. However, the actual impact on your clinic's bottom line is more nuanced. While the baseline conversion factor rose by over 3%, a new permanent 2.5% efficiency adjustment applied to non-time-based work Relative Value Units (RVUs) offsets those gains for certain services. Depending on your cli

Remote Therapeutic Monitoring (RTM) is the use of medical devices to collect non-physiological data, such as therapy adherence and pain levels, from patients at home. Despite its potential, many practices have resisted launching RTM programs, citing rigid rules that often resulted in significant clinical effort going unreimbursed. What changed with RTM billing in 2026? Beginning January 1, 2026, new RTM CPT codes allow PT and OT practices to bill certain Remote Therapeutic Mo

When a practice upgrades its clinical workflow say, moving from a platform like TherapyNotes to a system like Jane, backed by a clearinghouse like ClaimMD there is usually a lot of excitement. You look forward to cleaner interfaces, better scheduling, and fresh features. You check the boxes to link your new clearinghouse, hit submit on a few test claims, see them go through successfully, and assume the transition is complete. Then, two weeks pass. You know you’ve had claims p

It’s a scenario that makes every private practice owner’s stomach drop. You pull your weekly remittance advice, expecting a healthy reimbursement for a complex patient session where you billed multiple units or multiple distinct codes. Instead, the payment that hits your account is a fraction of what you calculated. Your first instinct? Call it an underpayment, blame a payer glitch, and gear up for a timely filing appeal. But before you spend hours on hold or drafting appeal

If you have been wondering whether Medicare still reimburses virtual therapy visits, the direct answer is yes. Physical therapists (PTs), occupational therapists (OTs), speech-language pathologists (SLPs), and audiologists remain fully eligible to bill Medicare for Telehealth services through December 31, 2027. While political debates and temporary funding fights caused confusion early in the year, Congress officially resolved the status of therapy Telehealth. Here is what ha

It is one of the most frustrating notifications a private practice owner can receive. You submit a clean batch of claims, wait weeks for reimbursement, and instead open a Remittance Advice marked with a rejection code: Denied for Incorrect NPI. This specific rejection is incredibly common, yet completely avoidable. The most frustrating part is that an incorrect NPI claim denial often has absolutely nothing to do with you doing anything wrong clinically. Your NPI is real, your

It is a moment of total panic. You log into your billing portal or open the mail to find a notice from an insurance company stating you have been overpaid. They want their money back. To make matters worse, the notice is for claims you successfully processed and closed a year or more ago. If your stomach drops when you see these letters, you are not alone. This is happening constantly right now. Insurance audits and retrospective demands are skyrocketing across the mental hea

You submit a batch of claims through your clearinghouse, check your dashboard a week later, and notice a handful are marked as pending. Another week passes, then a month, and nothing moves. The money sits in administrative limbo while your practice overhead keeps running. For solo and small group mental health, physical therapy, occupational therapy, and speech-language pathology practices, watching revenue freeze behind an insurance wall is one of the more demoralizing parts

By Danielle Wagar, CPES | Upstate Healthcare Admin Here is a scenario that plays out in mental health practices regularly: a provider completes Medicare enrollment, receives their PTAN, and starts seeing Medicare patients. A few months in, they notice some Medicare patients have cards that say Humana, UnitedHealthcare, or Aetna. Claims are submitting to the wrong payer. Prior authorization requirements keep appearing unexpectedly. The answer is that Medicare is not one thing.

By Danielle Wagar, CPES | Upstate Healthcare Admin Blue Cross Blue Shield is not a single insurance company. This is the thing most providers do not fully understand when they get credentialed with their local BCBS plan - and it is why BCBS claims can behave so differently depending on the patient in front of you. BCBS is a federation of 33 independent, locally operated member plans. When your patient has a BCBS plan from another state, the BlueCard Program governs how their

By Danielle Wagar, CPES | Upstate Healthcare Admin If you bill for telehealth sessions, you have almost certainly encountered modifier 95 and modifier GT. You may have used them interchangeably. You may have used the wrong one without knowing it and had no idea why claims denied. This guide clarifies exactly when each modifier applies and why using the wrong one will get your claims denied. What Telehealth Modifiers Do Telehealth modifiers are codes appended to a CPT procedur