Episode 242 | All Things Medicare: Credentialing, Billing, and Audit Proof Documentation with Gabrielle Juliano-Villani

Maureen Werrbach (00:00:02) – Welcome to The Group Practice Exchange Podcast, where we talk about all things related to group practice ownership. I’m your host, Maureen Werrbach. 

 

This episode is sponsored by Therapy Notes. Therapy notes is my favorite EHR, and it’s one that I’ve been using in my own group practice since 2014. They’ve got everything you need to be successful in your group practice, and they’re constantly making updates and have live support. If you want two free months of therapy notes, go to therapynotes.com/r/thegrouppracticeexchange. 

 

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Hey everyone, welcome to another episode of the Group Practice Exchange podcast. Today I have on Gabrielle Juliano-Villani, who is a leadership coach and trainer and business consultant and a therapist in Florida. You might have heard from her because she’s been in my magazine.

 

Maureen Werrbach (00:01:27) – She’s also all around when it comes to coaching practices. And I want to say, like, how I know you most is through you having your own group practice and then selling it because you’re one of the I mean, OG, I feel like of larger group practices that have sold out. Get this happening down the line now. But you went to seven figures sold in 2021, and now I get to do all the things you love to do minus employees. Sound so beautiful.

 

Gabrielle Juliano-Villani (00:01:55) – I’m pretty close to my dream life. I’m like 95% there. So yeah, I’m happy now.

 

Maureen Werrbach (00:02:02) – I mean, you get to host retreats in Belize and I’m so excited that I get to go to it in June.

 

Gabrielle Juliano-Villani (00:02:09) – I know I can’t wait either. I’m so excited to be there with you and to be in hammocks on overwater bungalows and watching the eagle rays go by in the water, watching the sunrise. It’s going to be amazing. Yeah.

 

Maureen Werrbach (00:02:22) – So, you know, less fun than that, but important nonetheless is today we’re going to be talking about all things Medicare related, because this is definitely not an area of expertise for me.

 

Maureen Werrbach (00:02:35) – And this is one of the things that you do a lot of coaching on is just all things Medicare, you know, credentialing, billing, auditing, documentation. And so that’s what we’re going to be doing today obviously through the lens of group practice ownership. So I thank you for being here.

 

Gabrielle Juliano-Villani (00:02:51) – Thank you for having me. I know this is like a very weird niche and a weird thing to be a subject matter expert in, but I knew one of these days it would come in handy. And it has. Yeah.

 

Maureen Werrbach (00:03:04) – I was telling you right before we started recording that we started taking, well, one, we started taking Medicare in my own practice, probably like six years ago. One, it was like a lesson learned of how because I’m not a social worker, I’m a counselor, which I guess now has changed because now they accept counselors. But previously they didn’t. I didn’t have that an LCSW. I’m an LCC and I didn’t realize you have to like, opt out of it. And so I had social workers in my practice.

 

Maureen Werrbach (00:03:30) – You know, they are not business owners. They didn’t realize they had to opt out. And so when I finally figured it out, we’re like, well, let me look into this. And we ended up getting credentialed and started taking it. And it was the biggest pain in my butt way back when. So I’m so excited to hear, like, because I’m a person who likes to accept insurance, ones that, you know, pay well or pay the best out of all the ones that are there in Medicare. You know, back then, I don’t know how much it’s changed because we actually got out a handful of years ago because my billing person literally was like, I cannot keep up because sometimes it would be their secondary. The EHRs wouldn’t send, you know, like from primary to secondary, right. And she was like, it’s just like so much work for a very small percentage of people that we were seeing at the time. So I’m excited to actually hear what the landscape is looking like these days and how to help people just navigate, because even just applying was a mess and a half.

 

Gabrielle Juliano-Villani (00:04:25) – The application is the worst part. That’s what I always say it is. It’s a pain in the ass and it’s very like, it looks like this system was built in 1980, which it probably was, and it has not been updated since then. And it’s very like archaic. And they ask questions in a weird way because it’s very like medically based. So the application is a pain. Once you get through that. I will say the billing, if people have straight Medicare and not a Medicare Advantage plan, the billing is actually usually pretty straightforward. And I had very I can count on one hand the problems that we had with just regular straight Medicare clients, and we were like 80 to 90% Medicare in my practice. So that’s a good thing.

 

Maureen Werrbach (00:05:12) – That is a good thing actually.

 

Gabrielle Juliano-Villani (00:05:14) – The rates vary. So in some states like I know for sure California, the rates there suck and they’re really low. But in some other states, like I was just consulting with somebody in Washington state recently and she was like, this actually pays higher than some of my other insurance payers.

 

Gabrielle Juliano-Villani (00:05:30) – And I had no idea. So and that’s what pushed her over the edge, actually. She’s like, I didn’t think I wanted to do this, but now I do because I’m going to get paid more than I thought I would. So it does vary based on your region. I know in Illinois it’s not the highest. but in some other states it is. And in Colorado, where my practice was, it did pay well for that time.

 

Maureen Werrbach (00:05:51) – So and I know all other insurances recently, like in the past few years, have started really focusing their rates based on like. The care reimbursements. And, you know, Medicare makes shifts to theirs, sometimes by pennies every year, you know? So I guess I want to know what are the benefits, aside from just being in-network with an insurance and, you know, allowing more accessibility, what are some of the benefits to thinking about accepting it? Because I think it’s not usually the natural first insurance people are thinking of unless they’re working with, like, you know, older populations.

 

Gabrielle Juliano-Villani (00:06:26) – Yeah. And that’s why I started taking it.

 

Maureen Werrbach (00:06:30) – Which makes sense.

 

Gabrielle Juliano-Villani (00:06:31) – Yeah. So that was, you know, for me, because when I first started my practice, when it was just me, I did work with mostly older adults and people with disabilities, which are people on Medicare and the other, you know, pros to accepting Medicare, being a Medicare provider is that there are not enough providers. There’s a huge lack of providers, and there’s still is. I was interviewed for a segment on NBC news a couple of weeks ago. I saw it, and I was sitting right here and they told me, which I don’t even know where they got this from, but they told me when they were interviewing me that only 11% now of like the new LPC and LMF pts that can opt in or opting in. So there’s still a really, really big lack of providers. So that means that it can be a good stream of referrals and clients for you. The clients are really amazing. They’re very rewarding to work with.

 

Gabrielle Juliano-Villani (00:07:27) – You can see them during the day. That’s another plus. I never worked nights and weekends ever and again, like it depends on your state, but in some states it doesn’t pay terribly and it pays on par or even more than commercial insurance. So it could be another way to have, again, just another stream of referrals and clients that are coming to you.

 

Maureen Werrbach (00:07:49) – I have a question about it. Yeah, as a group practice, and I’m not going to say the wording. Right, because I don’t remember. It’s been so long, but I remember they had like two ways, like you could credential and then you could credential credential. And there’s like a word for it, like you got it was like a higher rate because you were like a I don’t know if it’s like levels non pa and PA.

 

Gabrielle Juliano-Villani (00:08:11) – Yes, yes. You got there. Can you.

 

Maureen Werrbach (00:08:14) – Explain that. Because I remember being like they have different rates and you still have to jump through hoops to do either one of them. And one of them is like more in-network than the other.

 

Maureen Werrbach (00:08:23) – Right. I don’t know.

 

Gabrielle Juliano-Villani (00:08:24) – Yeah it’s weird. And the non PA which stands for non-participating is technically not allowed I guess is the word for master’s level mental health therapists and counselors. But then a couple of different regions and Illinois might be one of them. And I know like Texas is another one where they do allow it. And so it just kind of like depends. And I don’t really know how that works because it’s like written into the Social Security Act that we’re not supposed to be non PA, but then some people approve it like somebody and my Facebook group just and I think she was in Texas actually she did post that she like got approved as a non PA provider. And that’s it’s kind of like Tricare with like their certified out-of-network. It’s like similar to that where like you are in network, but you don’t have to accept the rate that Medicare gives you. So you can bill your client a higher rate. And that is called a limiting charge. And that depends on regions too. But it’s usually like up to 15% more than what Medicare pays you.

 

Gabrielle Juliano-Villani (00:09:25) – But then it means that the client has the higher coinsurance, but you also get paid more. So it depends. Okay.

 

Maureen Werrbach (00:09:32) – I just remember being like I don’t understand. So we were not non Pas. I wanted to be that Pas because I saw that the rate was it was like a little higher. I didn’t. Yeah. And they said we could but it was like you have to do it within. You know I think it’s like November. Maybe it’s it goes with the insurance cycle or whatever, you know. yeah. And so whenever I had applied, I was like, so now I have to apply to be in and then go through the hoops to like undo that to get into the non pas. It felt very confusing. So we were taking, you know, we were ended up being in-network as participating. But that’s good to know. So some states don’t allow it. Yeah I guess those that are allowing it shouldn’t be allowing it.

 

Gabrielle Juliano-Villani (00:10:12) – I don’t know because I always thought and I even have looked at like the CMS guidelines, it says like and at this point this is what for counselors.

 

Gabrielle Juliano-Villani (00:10:21) – But it’s like social workers can’t be non pas. So that’s always what I went with. But then people again in my group were messaging me and emailing me and being like, but we can be like, look at this email I got from the Texas NSW Association. I’m like, And then somebody did post that. She had her approval letter from Medicare that said she was non Pas. So it depends. But in most cases either you are participating in your billing Medicare or you opt out and you’re not billing Medicare and clients are paying you privately.

 

Maureen Werrbach (00:10:52) – Okay. All right. So I know we talked a little bit about some of the common challenges. One being an old archaic application. And process and the wording. What other challenges do you see for those that do go forward and want to be in network?

 

Gabrielle Juliano-Villani (00:11:09) – I think one of the other challenges is that there are some little nuances that you need to understand, and once you understand those, it’s not as complicated. But if you don’t understand them, it is a little bit complicated.

 

Gabrielle Juliano-Villani (00:11:20) – And one of those is that, you know, if you are a master’s level therapist, you get 75% of the posted rate. So people get confused about that because then they’re like, I got paid way less than I thought I was going to. So you get 75% of the posted rate, and only 80% of that 75% comes from Medicare. So a lot of Medicare clients have something called a supplemental or a medigap plan, which pays for that 20% co-insurance. So you get paid 80% for Medicare, and then it gets forwarded to that Medigap plan. Who pays you that 20% co-insurance? But not all of them pay the 20% coinsurance. So these are some of those like little things that I go through in depth, which is I know it’s not exciting, but I do talk about them in depth in my courses so you can get an understanding. And I think the other really big thing that burns people is not knowing the difference between regular Medicare and Medicare Advantage, because those are two separate things also.

 

Maureen Werrbach (00:12:22) – Explain that for me because I don’t know the difference.

 

Gabrielle Juliano-Villani (00:12:25) – See, this is why we need to talk about it so people can be educated because they are different. So when people become Medicare eligible, which, by the way, I will say really quickly that folks who are on SSDI for two years or more can also get Medicare. So you will see, I’ve had Medicare clients that were 18 years old. So you can have younger clients who are on Medicare, but they can get like regular traditional Medicare from the government, which, you know, is like that red, white and blue card. And that’s what we’re talking about, like this archaic pain in the ass credentialing application. But some people get I shouldn’t say they get roped in, but they kind of do get roped in to a Medicare advantage plan, which is like privatized Medicare. And that means that the commercial insurer is the one who manages that plan. So with regular Medicare, there’s different parts for like hospitals and prescriptions. And with Medicare Advantage, they roll all of that into one. So it’s kind of like a normal commercial insurance plan where, you know, it covers your hospital stays, it covers your OT visits, it covers your prescriptions, you have different copays.

 

Gabrielle Juliano-Villani (00:13:33) – But the reason why that’s so important is because those Medicare Advantage plans are managed by the commercial insurer. You have to be in network with those specific plans to build them unless they have out-of-network benefits, but most of the time they don’t.

 

Maureen Werrbach (00:13:50) – A United Medicare Advantage plan you’d be billing United and not Medicare.

 

Gabrielle Juliano-Villani (00:13:53) – Exactly.

 

Maureen Werrbach (00:13:54) – And so then it’s really making sure that you, as the practice owner, have some system in place to be able to benefit, check and not assume Medicare is Medicare.

 

Gabrielle Juliano-Villani (00:14:03) – Yes, because clients don’t know the difference. And they’ll be like, I have Medicare and I have UnitedHealthCare. And it’s like, okay, but is it a UnitedHealthCare supplemental plan that’s a supplement to regular Medicare, or is it UnitedHealthCare Medicare Advantage, because clients will describe those things the same because they don’t understand the difference.

 

Maureen Werrbach (00:14:22) – And so Medicare Advantage are their rates based off of the Medicare rates or whatever the contracted rates are with, like United or the private and health insurance plan.

 

Gabrielle Juliano-Villani (00:14:31) – They have their own contracted rates, and they’re different usually than their normal commercial insurance rates.

 

Gabrielle Juliano-Villani (00:14:38) – And they’re usually lower. Not always. But the UnitedHealthCare specifically, they’re like always lower.

 

Maureen Werrbach (00:14:44) – Okay. So I mean, that is really complicated if you don’t know what to look for, you know, as a business owner who accepts insurance, it’s not complicated to hear it. It’s like, okay, I get it. You know, these are the different things. But I think this is one of those areas where, like, you don’t know what you don’t know. And I can see a lot of practices joining thinking they’re just applying to Medicare. It’s one bucket that they’re going into and that it’s not necessarily the case.

 

Gabrielle Juliano-Villani (00:15:13) – Yeah. And that’s where the confusion and the billing problems start to come in and get convoluted. So that’s always my advice is like if you do want to accept Medicare, like you do need to be very clear and get as much information from clients, whether you’re the one doing that or your admin is from the very beginning. So you can understand. So there’s less problems later.

 

Maureen Werrbach (00:15:35) – Yeah, that makes sense. What would you say if someone was thinking about accepting Medicare or not. Like what are the considerations that you think group practice owners should have before choosing to accept? Like I guess I would think administrative support, like if you’re a small group practice and you’re, you know, have no admin or don’t have a biller or maybe have a, you know, a biller who lives. Really just click submit claims. Yeah, that would be maybe a big consideration on my end thinking like, do you have the time to do the extra administrative work involved with it? Is there anything else you’re thinking of?

 

Gabrielle Juliano-Villani (00:16:13) – I think just having staff that enjoys or understands working with this population, because it does look a little bit different. A lot of times, like a caregiver might be involved or like, you know, a client’s kids, for example, will be calling to set up services like we got that a lot. So it just looks a little bit different. And our practice, like I said, was we saw a lot of Medicare clients.

 

Gabrielle Juliano-Villani (00:16:38) – So I was kind of used to that. But we used to get referrals all the time from other therapists in the community, and they’d be like, this client is inappropriate for therapy. They’re old and they’re just not really showing up. And I’m like, send them to me. I will take them. And like, and we’re still at my old practice seeing some of those clients because it just looks different.

 

Maureen Werrbach (00:16:57) – It makes a lot of sense because I think about like, you know, policies and things that, you know, each practice might have that are different. And like one policy that’s common is that intake paperwork needs to be completed before the first session, where maybe in this scenario, that might be difficult for some who might not have a computer or that ability or like I know some practices have, like if you’re an adult, you need to be the one scheduling your appointments. And I can see where that if you’re not versed in understanding just that aspect of humans that needed therapy, like, you know, I get the idea of setting up policies that like simplify and streamline things, especially if you have, you know, hundreds of therapists.

 

Maureen Werrbach (00:17:38) – It would be so difficult if you had every client doing different things. But in a case like this, it would mean adjusting and accommodating in some ways. So yeah, accommodations definitely would be a consideration too. Like do you have the capacity to like set up some sort of accommodations when it comes to administrative expectations or allowing other family members to be a part of an adult’s care? That makes sense.

 

Gabrielle Juliano-Villani (00:18:03) – And there’s also, you know, a lot of other things that happen as we age, unfortunately, and that, you know, could be somebody has low vision or they’re hard of hearing. And so those are other. And of course, for those you could bill interactive complexity, but those are other things that take time to set up and to work around. And not everybody is willing to do that. But that was something that I felt like it was an administrative headache sometimes. But I also felt really proud that my practice was able to do that. And my clinicians loved doing that. Like, I remember we had a client who they would meet on zoom, you know, just because of the audio visual piece.

 

Gabrielle Juliano-Villani (00:18:41) – But she couldn’t speak. And so they would just like, text back and forth in the chat. And like, she had other ways of like getting around that. And nobody else in the community wanted to see this client. And, you know, that’s how we got this referral is like her social worker at her doctor’s office was like, nobody wants to work with her. And she really, really is engaged and needs help. And she was engaged. She came every week. She never missed a session. And so that just made me feel really good and proud that we were able to help folks like that who other people didn’t want to, which I understand, it’s more work.

 

Maureen Werrbach (00:19:12) – Yeah, I just had a master class the hour before this on Pip’s I know, performance improvement plans totally different than what we’re talking about. But I was talking a lot about like, accommodations and, you know, before putting a pip in place, like, is it a performance issue or is it that this person is in need of an accommodation and you haven’t done the work as an employer to make sure that you’re setting up an accommodation that can set them up for success? And I guess translating that over to this is like interesting in hearing you talk about how, you know, practices who and like mine, who like streamlined systems because especially when you’re larger, it can feel chaotic otherwise.

 

Maureen Werrbach (00:19:52) – Like how does that play into a lack of accommodation, you know, in this situation. So it’s good to hear from you. Yeah.

 

Gabrielle Juliano-Villani (00:20:02) – It’s a fine balance. And there were definitely I mean, there was more paperwork at times. And I remember like when we had to pivot very quickly to telehealth because my practice before Covid was in home. And then of course, the pandemic changed that. And that was a whole shit show because I was actually in Key West. It was my birthday when they announced it. And so I had to, like, fly home, figure out telehealth and like one day and get all the consents. And as we kept getting new clients during this time, obviously when a lot of our practices blew up, and even with older adults even more so because a lot of them were literally locked in their rooms and their nursing homes and assisted living facilities, and they didn’t have a computer, they barely had like a flip phone. So I had to print out all the consents, all of the policies and procedures, put a prepaid envelope in the envelope with that stuff and mail it to clients and have them mail it.

 

Gabrielle Juliano-Villani (00:21:00) – Back to me and then upload it into simple practice, which obviously was very time consuming. But sometimes I kind of like doing stuff like that because it has a beginning and it has an end.

 

Maureen Werrbach (00:21:13) – I can understand that too. Okay, I know we’re close to the end. My last question for you relates to, I think, what you like doing now, post practice ownership is like stepping into what you love most and like finding balance. What is your suggestion for practice owners on like just staying balanced in? If they’re trying to make that decision and making the decision to decide to accept Medicare, like how to just find that balance because it does feel like there is just in what you’ve explained. There’s a lot that can happen client to client, that can’t be streamlined and optimized, like how I talk about all the time. So how do you what’s your suggestion for keeping that sort of balance and not feeling so overwhelmed and burnt out by it, while also if it’s aligned with your vision and your values to be able to do it.

 

Gabrielle Juliano-Villani (00:22:07) – Exactly. So I think it’s thinking about your vision and your values. And does Medicare fit in with that? And if it doesn’t, it’s okay. It doesn’t have to. And I do feel because I’m also a big proponent of delegating and streamlining, you still can have systems and processes in place for those, but it just might look different. And also remembering you don’t have to take every client that walks in the door. So maybe specifically you just want to work with chronic illness, or you just want to work with grief and loss. So if somebody has Medicare but they’re struggling with family estrangement or something and that’s not in your wheelhouse, then you can simply say that and you can only, you know, still niche down and work with the clients that you want to work with or that your clinicians want to work with. Because if you are just taking Medicare because you’re desperate and you need money and you want another revenue stream, and you know it will bring you a lot of clients, which it will, but you don’t want to overextend yourself and say yes when you should instead be saying no.

 

Gabrielle Juliano-Villani (00:23:13) – Yep.

 

Maureen Werrbach (00:23:14) – Makes sense. All right. Related. Based off of the last question, what are you doing in June? Because as a person who owned a group practice and really, you know, it’s so common, especially I feel like since January of this year, I feel like I’ve seen a lot of more of it. People wanting to close their practices down, feeling burnt out, overwhelmed. That’s been there since Covid, but weird increase just in 2024 that I’m seeing, which is what prompted me when I saw it. Your thing to be like, okay, I’m doing it, but just not my normal. Like I am so introverted, I don’t want to really talk to other people. I don’t do yoga or any of that stuff, and I’m putting myself in all of the stuff that you’re doing there because of like the concept of it. So bring it up really quick and where people can find it, because this could be helpful for anyone who wants to accept Medicare to get prepared.

 

Gabrielle Juliano-Villani (00:24:04) – It could, and I agree with you.

 

Gabrielle Juliano-Villani (00:24:06) – I’ve also seen a lot of uptick in my discovery calls. I just I had three people schedule a discovery call with me today, and all of them said the same thing, that they’re burnt out and stuck, and they’re thinking about selling or they’re not sure what to do. And I think it’s just like a culmination of the last couple of years. And so what’s really helped me move through my own burnout, my own mindset shifts that I had to make was nervous system regulation and the mind body connection, because we all have one. And I wish that I just would have learned this like 10 or 15 years ago, but I didn’t, and I’ve learned it now, and it absolutely relates to business ownership and leadership, because our own shit comes up with that all the time. And I will tell you, if you think it doesn’t, you’re wrong. Your mindset, your perspective, all the stuff that we carry with us, it absolutely has a huge impact on how we run our businesses. And you can’t run a business if you’re constantly in fight or flight or freeze.

 

Gabrielle Juliano-Villani (00:25:08) – And so that’s a little bit about what I’m teaching in Belize is deepening that mind body connection, how to understand yourself better and know when you’re in those places, teaching you skills to cope and how to manage when you’re in those places, because that’s totally normal to be there. And then, you know, a little sound healing, a little meditation, a little tanning, little snorkeling, yummy food to put it all together.

 

Maureen Werrbach (00:25:34) – I’m so excited I got in when you guys are snorkeling, I’m getting to scuba dive. She approved. So I’m like, so excited for that. There’s only two spots left, but where can they go to check it out?

 

Gabrielle Juliano-Villani (00:25:44) – You can find me on Instagram @GJVconsulting or you can go to my website www.GabrielleJulianoVillani.com.

 

Maureen Werrbach (00:25:52) – Perfect. Thank you Gabrielle.

 

Gabrielle Juliano-Villani (00:25:54) – Thank you for having me.

 

Maureen Werrbach (00:25:56) – Yeah. And I will make sure to put the links in the show notes as well for people.

 

Gabrielle Juliano-Villani (00:26:01) – Perfect.

 

Maureen Werrbach (00:26:02) – Well, good seeing you again.

 

Gabrielle Juliano-Villani (00:26:03) – Thank you for having me. I can’t wait to see you in June.

 

Gabrielle Juliano-Villani (00:26:06) – In person?

 

Maureen Werrbach (00:26:07) – Yes. All right. I’ll talk to you later. Thanks for listening. Give us five stars on whatever podcast streaming service you use and I’ll see you next week.