- American Insurance is incredibly complicated, but understanding it empowers you and can save you thousands in your physical and mental health care
- I do all of my own billing, and while I’m not an insurance broker I know a lot about common pitfalls that leave people confused and on the hook with surprise costs.
- This multi-part series will break down this complicated system so you can get the most out of your benefits, access the care you need, and keep you as protected as possible from unexpected costs
- Starting Broad. In the insurance world providers are divided into two categories: In Network and Out of Network. All plans have “in-network” and some plans have “out of network” benefits and they are most often different. Usually it costs you less to see someone in network, BUT depending on the plan some have excellent benefits in both categories
- In Network:
- The total amount a provider is paid per session is determined by the insurance company
- How much you as a client pays is determined by the insurance company
- Be on the lookout for carve outs! See post for details
- Out of Network:
- The total amount the provider is paid is determined by the PROVIDER.
- If your insurance plan has out of network benefits insurance may chip in none, some, or all of the cost depending on the specifics of your plan
- Some providers are willing to send these sessions to insurance to help you save money. Some are not. Ask your provider.
- Both in-work and out of network:
- When using insurance know that your insurance company collects information about you to determine whether or not they consider this a “valid” use of the medical treatment provided. To cover a mental health session they always require a diagnosis.
- Yes. If you are in therapy and you or your therapist are sending claims to insurance this means you have a diagnosis. You have every right to ask what that diagnosis is, and to understand what symptoms your provider sees in you that led them to making that diagnosis.
- If you want to know costs in advance of scheduling with a provider you can ask the provider if they are in or out of network, and you can contact your insurance company to verify. You can also contact your insurance company and ask what you should expect your “out of pocket” (i.e. your personal) costs should be.
- When calling insurance you can provide the CPT codes (these are billing codes providers use) to get exact dollar amounts:
- Initial appointment is often: 90791
- Additional appointments are often: 90837, 90834, and 90832 for individual work or 90847 and 90846 for family / couples work
One major barrier to treatment in the United States – our incredibly complex insurance system.
Insurance networks have two categories: Providers that are in -network and providers that are out-of-network.
Some key differences:
A provider who is IN network is a provider who has signed a contract and agreed to set of rules for how to operate their practice.
How this effects you: This means the provider has agreed to accept fees at a certain rate for the treatment they provide. This usually means the provider is responsible for billing the insurance company on your behalf.
Example (with made up numbers): I say my fee for therapy is $150/hour. The insurance company says to be in our network you have to agree to be paid $100/hour. I can decide to accept that, try to bargain for a higher rate, or decide not to be in network, but once I decide I am “in the network” I have to agree to accept the rate the insurance company and I agreed to for every client I see who has that insurance.
Things that make In-network more complicated:
(1) There is a thing called “carve outs”. This is when you have a plan from one insurance company but they “carve out” a particular kind of health care to another insurance company. I.e. it says “Insurance A” on your card, but ACTUALLY your mental health benefits are through “Insurance company B”. The only way to know if this is the case with you plan is to call and ask before billing happens.
(2) Insurance companies can decide change how much they pay providers. Which means your costs can change even if your plan doesn’t.
A provider who is OUT of network has decided not to sign a contact with an insurance company. Those providers set their own fees, which means the insurance company has no say over how much you will pay per session.
Example continued: I say my fee is $150. You pay me $150. The insurance company doesn’t have any say over it.
At the end of the day, you are responsible for the cost of your healthcare, so be your own advocate, protect your finances, and call your insurance company to make sure you understand what they will cover and what they won’t.
Notes:
- I’m quite serious that knowing and understanding how insurance works can save you huge amounts of money. I can’t tell you how many times claims have been processed in a manner inconsistent with how I or my clients have understood their plans to work – and understanding this system has enabled both me and them to challenge an insurance company to have payments made where they were previously denied.
- If you’re going to call an insurance company to check on costs, ask for a confirmation number at the end of the call ad write down / keep that number. If there is as issue down the road they will be able to find record of your call when you supply that confirmation number – which may be the “evidence” that you need to get the company to operate in a manner consistent with what they told you at that time (and yes, I have seen this happen many times before).
- In Illinois we have something called the “Illinois Dept of Insurance”. I am guessing other states have it too if you want to dig around a bit. This is a government agency that investigates fraudulent uses of insurance by both providers and by insurance companies. If you are spinning because you know something isn’t right with how payment or insurance is being handled this free service will step in on your behalf and investigate. Don’t be afraid to file a claim, I’ve filed half a dozen or so over my last 10 years in business and it works. Sometimes we all need an outside advocate. https://mc.insurance.illinois.gov/messagecenter.nsf