Mental Health Billing Made Easy

One therapist’s journey to take the headache out of mental health billing 

By Leila Ghaznavi

Alyssa Ashenfarb is a licensed psychotherapist located in New York City who recently transitioned to running her own private practice. I had the pleasure of meeting with Alyssa to discuss how she streamlined her mental health billing so she could spend more time with clients and less time on paperwork. 

Thank you for taking the time to speak with me today. Could you tell me a bit about yourself and your practice?

I have my own practice in New York City that I started about a year and a half ago. My specialty is people in their 20s and 30s who are struggling with relationship issues and are having difficulty connecting with the people around them, either romantically or with friends and family.

That’s an interesting population to serve. What attracted you to that group?

It's been a windy road. It started off as an interest in trauma. The reason I was interested in trauma is that there's a beauty about the symptoms. There's something resilient about how every symptom is actually an adaptation that our body is using to try to protect us from potential danger. I started with things I call “big T” trauma, for example, sexual assault, or a car accident, or something really acute. From there, I became interested in “little T” trauma. This is usually more chronic, for example, attachment ruptures and/or people who struggle internally, but don't really have a name for it or a specific diagnosis. For example, if a parent had a mental health issue and was doing everything they could, but their child was feeling empty or lonely inside because it was too hard for the parent to be present or responsive. That is more of the work I'm interested in and how that manifests and even replays in other relationships throughout life.

Thank you for doing that work. Since you're a solo practitioner, what has your process been when handling Superbills and managing mental health care billing?

Fortunately, I don't have to deal with that now. So many times when I was working at my old group practice, things would be filed wrong, or filed late, or there would be the wrong address and it would mess up claims for months. Fortunately, I haven’t had to deal with that in my own practice since I'm out of network. When I first started my practice, it was something I was really anxious about because I was committed to doing the billing for my clients. A lot of clients say, “I want to devote all this time, money, and effort into my mental health and therapy but I literally can't figure out how to get reimbursed.” So it becomes a huge barrier to mental health. 

But when I started doing it on my own, I couldn't figure it out. Claims got bounced back to me or the insurance company would say I had to pre-enroll and that process would take six months. So, in a panic, I contacted My Wellbeing, who led me to Nirvana. Now, Nirvana files all of my claims. My clients are so excited about it! They can see their claims online and they know how much they will get reimbursed. Now I can talk openly about finances, which actually helps the therapy process. It's been beyond helpful.

Given the experience you've had managing Superbills and mental health billing, what advice do you have for other therapists?

When I first said that I wanted to handle the billing for my clients, a lot of the therapists I know said, “Don't do it. You go out of network for a reason. You don't have to deal with insurance.” I think they had that motto because it is so difficult when you do it by yourself. My message would be: recruit help. Use a service like Nirvana. 

I can’t tell you how many clients come to see me with questions like: “What is a deductible? How much do I get reimbursed?” These are all questions that impede a client’s ability to get therapy if they can’t find answers. So if you can file claims, do it. And if you can’t, recruit a service to do it for you. But don't just not do it because someone told you that it’s hard. Mental health billing doesn't have to be difficult.

Can you talk more about how challenges in mental health billing are impacting therapy? 

Part of therapy is talking about things that make everybody uncomfortable. For example, if I have a client come in and say, “I used to be able to afford this, but now I can't. What should I do?” I have concrete information from Nirvana about how much they're getting reimbursed. Now we can work together to determine if a sliding scale is appropriate because I know they're struggling, I know they're committed, and we have the financial information to make an informed decision.

We can also openly discuss budgeting. I can say, “We know you'll be reimbursed and it's going to come in the next month. So you don't have to feel so anxious about your finances with therapy because it's money that's coming back to you.” Then we can talk about trust in the system or their ability to trust me. Or how, if I give them a sliding scale, I can still give them good therapy and it doesn't have to be less effective therapy just because the price is lower. They can trust me to always do my best. So having a reliable way to understand a patient’s health insurance opens all kinds of doors.

I haven’t heard it discussed that way before. How a client may interpret a sliding scale as meaning that they’re getting low-quality therapy since they pay a discounted rate. 

It’s about building trust so the client has confidence in you when you say, “I'm always going to be here for you, no matter what you're paying.” That you actually mean it.  Clients can experience a lot of anxiety about whether someone will stay committed to them. I find that this anxiety is mirrored in the discussion about finances. Clients will say, “I can come in every other week at your full price.” And I will definitively reply, “I would much prefer to see you at a lower price every week so we can do real work.” 

At first, they're skeptical because they're wondering: Why would you want to see me more often for less money? Then sometimes they work it out in their head: Oh, you must want more money aggregated. It takes a lot of sessions to work through those concerns and to reinforce that I genuinely believe our work will be most effective if we see each other weekly. Therefore, I prefer to give them a sliding scale. 

My job isn’t just a job—I love it. I'm genuinely curious, and I want to learn more and help my clients to the best of my abilities. A lot of people will come in saying, “I'm looking to solve these problems.” I see my job more as: we work together, get curious about what's going on in your life and what problems manifest because of the way you learned to see the world. It is more of a collaborative process. People want to stay because they know we're working together. Versus it's all on me as the healer to be some deus ex machina in their lives. I'm not going to solve your problems because I don't know the answers to life, but we can work on this together and get curious. 

How did transitioning to Nirvana help improve your mental health billing so you could build that trust ladder?

With Nirvana, my clients trust that they'll be reimbursed. In the past, with the group practice that I worked at we'd say we were submitting claims. And we were submitting claims but they got bounced back so often that it would take months for clients to get reimbursed. 

Nirvana gives me instant access to the status of my clients’ claims. For example, one of my clients mistakenly put his mother’s address on his claim and he wasn't getting reimbursed. I just had to look at the portal to identify the issue and we were able to fix it right away.  

Most importantly with Nirvana, my clients get reimbursed within 30 days consistently and reliably. They’re not asking, “How much is going to come? What address is it going to go to? Is it going to get delayed?” 

There’s a big difference in someone’s budget if money comes back in 30 days versus 90 days. What would you recommend to other therapists struggling with Superbills?

Recruit help. If there's a billing system, use it. There's no reason to struggle. I just had a session with one of my clients and we were discussing how just because you can do something alone doesn't mean you have to. That itself can be the whole point of therapy because it's so relational. We need the people around us. We have to learn to trust them and lean on them. That's what I do with mental health billing. You need to learn to trust your resources and then use them. Don't do it alone.

There is so much about the American independent mindset in that statement. If you can’t do everything by yourself you’re falling short.

Yes! Especially with young and middle aged men. I'm constantly unpacking that with them. None of us have to live this cycle. Life can be a lot easier, and actually more joyful and connected when you lean on others. 

Given everything that we’ve talked about, what are the top three pieces of advice you’d give to other therapists looking to start their own practice? 

First, I'd say rather than working on filling your practice’s roster immediately, make sure a potential client is a good fit. The best indicator for success is a client’s relationship with the therapist. Don't just take whatever client comes along. You should really care about the client’s needs so you can build that relationship. 

Second is definitely consistency. We need consistency with others and consistency with ourselves in order for us to be able to have confidence and trust in the world around us.

And third? Hire a biller.