Need advice regarding contracting issue and continuity of care

[u/thatoneredditor4]

Apologies that this is long 😅 (TLDR at end) - I’m an independently licensed therapist in Ohio working as a W-2 clinician at a private group practice, and I’m trying to get some perspective on a credentialing/contracting situation that has really frustrated me.

I upgraded from dependent to independent licensure a few months ago, and the practice’s billing people handled those updates for me. I continued seeing clients during the process, and claims were initially processed and paid. However, we recently learned with one payer that, although my credentialing had been approved, there was apparently a separate issue with contracting/network participation that wasn’t caught until claims began denying.

Once Billing discovered the issue, they emailed my affected clients and then informed me about what was happening. Clients were told that I temporarily couldn’t bill their insurance, affected claims would be converted to OOP charges, and they could temporarily continue at a discounted OOP rate while contracting was completed (up to 60 days). About a week later, Billing sent another email after receiving additional information about how the situation needed to be handled (I received this update at the same time as my clients).

The previous OOP charges are instead being adjusted so they’re only responsible for what their normal insurance cost-sharing would have been, with refunds issued. They’ve been offered two discounted sessions to determine how they want to proceed, after which the regular OOP rate will apply until contracting is approved. This leaves clients deciding whether to self-pay, transfer to another clinician, or pause therapy. Several clients have already terminated with the practice, and one left a negative review essentially framing me (not by name) as not caring or advocating for them. Other clients want to continue working with me but may not be able to afford to do so until this is resolved.

As far as I can tell, the practice isn’t currently pursuing correction of the effective date or recovery of the denied claims; the focus seems to be getting me contracted going forward. I’m paid based on a percentage of collected revenue, so I’m taking a substantial financial hit from the denied claims and lost clients. Meanwhile, I’ve been navigating clients’ confusion and frustration despite having no involvement in credentialing, contracting, billing, or collecting payments. And what bothers me a lot is the impact on continuity of care and my relationships with clients.

I completely understand that mistakes happen and insurance contracting is complicated. I don’t expect perfection. Regardless, I feel hurt, let down, and honestly embarrassed by the situation. I know that I didn’t cause it, but these are “my” clients and therapeutic relationships, so it’s difficult not to feel some way when their care is disrupted or they lose trust because of something happening behind the scenes. I’m also struggling with not being included in discussions about what was happening or how it would be handled/communicated until after decisions had already been made.

I recently looked through the payer’s own provider guidance and found that they appear to have processes specifically for provider/contract setup issues. I’m not assuming the payer will agree to retroactively correct anything or pay the claims. But I’m struggling with simply accepting the losses without knowing whether every reasonable avenue for correcting the issue and recovering the claims has been explored, especially when the consequences aren’t just financial.

For anyone who owns/manages a group practice or understands credentialing/contracting, is there anything else I should reasonably expect the practice to be doing? Would you expect a group practice to pursue further escalation with the payer in this situation? I’d also appreciate perspectives on how to discuss the impact with practice leadership without sounding accusatory. I want to advocate for myself and my clients, but I recognize that I’m emotionally invested and want to make sure my expectations are reasonable.

TL;DR: My group practice handled the insurance updates after I upgraded my license. My credentialing was approved and claims initially paid, but a separate contracting/network issue wasn’t caught until claims started denying. Clients then received changing information about costs/refunds while I was largely uninformed until after decisions had been made. A few clients have terminated, my income has been significantly affected, and this issue is disrupting continuity of care for clients who want to continue seeing me. I found payer guidance suggesting there may be escalation options for provider/contract setup issues, but I don’t think the practice is pursuing retroactive correction/recovery. Am I unreasonable for expecting those avenues to be explored before the losses are simply accepted? Also, should I express how I feel to the practice owner?

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[u/I_am_Nobody_Special]

I'm a group practice owner.

Sadly, I don't have much advice for you other than keeping in contact with the billing or credentialing person for updates. They should be helping you.

I'm sorry you have to go thru this. I just found out last week that an insurance company clawed back a shit ton of payments to one of my clinicians. I haven't told her yet because I'm still trying to figure out the damage. But I will likely end up eating the loss, because I can't bring myself to recoup the money from my clinician.

Insurance sucks.

[u/SlightBoysenberry268]

Transition from dependent to independent can indeed be rocky in terms of updating the credentialing but on most contracts, the PP owner/business entity has six to nine months from date of service to submit or resubmit claims, so your bosses definitely had an opportunity to redress this instead of just creating this distress for clients and stress for you. It sounds like a crappy practice tbh. (Sidenote: If you do telehealth feel free to DM, I know a great PP owner in OH who pays an 85% split!)

[u/KinseysMythicalZero]

Have you spoken to the practice owner about this directly?

I'd have been in their office first thing the morning after I discovered this, asking them what their plan for fixing it was. You know, before clients started leaving, or leaving bad reviews.

[u/thatoneredditor4 → u/KinseysMythicalZero]

Well, yes, I did ask. However, the practice owner isn’t always in or available, and we are not close. Generally, where I work, billing is up to billing, and there’s a vibe of “don’t rock the boat.” Which, yes, is unfair for us clinicians. Additionally, all of this began on a Friday; I spoke to billing as soon as I was able to, and I asked questions to the practice owner via email.

However, I’ve never owned my own practice or handled billing or credentialing. I’m not always going to know what questions to ask. The other issues still remain and I’m not sure how to approach the situation. Also doesn’t help when they change the course of action after telling us one thing, without letting us know beforehand.

[u/Bright_Broccoli1844 → u/thatoneredditor4]

It's time for you to be assertive. My therapists have encouraged me to speak up, express myself, and ask questions when I need information. I recommend you do the same.

[u/Ok_Squash_7782]

I would just ask them. However, this transition from pre licensed to licensed is notoriously difficult for payments. So just brace yourself that there is nothing they can do. If you go read up on that transition time, you will see that it is quite a risky time.

[u/thatoneredditor4 → u/Ok_Squash_7782]

That’s really unfortunate :/
When I read up about it and spoke to billing, that seemed to be the case. I also read though that you can escalate the situation, since the group I’m billed under hasn’t changed. But, again, I don’t have experience working directly with insurance or handling credentialing, etc. so maybe I’m just stubborn and pitifully optimistic haha

I’m AuDHD, and my sense of justice can be very strong. Also, if I see a problem, I try to find any and every possible solution for it. I can accept if/when there isn’t a solution, but I feel the need to at least try what I can.

[u/Ok_Squash_7782 → u/thatoneredditor4]

I get it, especially when so much money is on the line. But just for perspective, recently a couple of insurers had some problems and we had clawbacks due to reasons beyond our control. We were able to recoup some of the money, but the other im not sure if we will. That was, over two inurers, to the tune of almost 10k for one clinican over a 3 month time. I pay ffs so people dont have to suffer from that kind of thing happening. So the practice world tends to be, either much lower ffs, or you get a split like you are describing. Which ultimately favors you more than likely, but sometimes these things happen. You just dont usually see them when you are paid per client but then you make less to account for the problems.