Understanding Insurance

by | Nov 11, 2019 | Insurance

Understanding Insurance is really complex and can be challenging when you’re trying to seek mental health counseling. Below I provide some bullet points based on our practices experience with insurance companies. I’ve also included the Pros/Cons of using insurance. 

 

Using Insurance (Pro’s and Con’s):

Pro’s:

Here are a list of Pro’s for using insurance for your mental health services.

  • You already pay (or your company pays) for your healthcare benefits, why not use them!
  • You receive discounted rates. For example our 55 minute session rate is $135 (goes up $5 each year). Out of pocket you pay that full rate. Using insurance you pay our contracted rate- this is what Turning Stone Counseling and your insurance company have agreed upon – it’s often reduced by $20-75 depending on the insurance company. 
  • It does help when you need to receive medications and/or more intensive services. Most of us cannot afford out of pocket expenses that come with many medications and/or inpatient services. 
  • Parity Law was passed in 2008 – This law requires insurance to view mental health and addiction services similar to receiving other medical care; therefore its atypical for an insurance company to consider our services specialty services making it a lower out of pocket expense. 

 

Con’s: 

Here is a list of Con’s for you to think about if you use your insurance.

  • You must have a diagnosis that can be billed to your insurance company. Therefore this is part of your legal medical record. This is so important! Take some time to read up on how this may affect things like obtaining life insurance, certain job. 
  • Insurance companies can dictate how long you are to be seen. Now this is not explicit but we have certainly worked with companies who restrict our sessions to under 52 minutes. That does not seem like a big deal but for some those extra 5-7 minutes can do wonders for the work being done in session. 
  • There may be a Cap on services. This is less frequent over the years but does still exist on certain plans. Another reason to know your benefits. 
  • A provider can terminate at any time and then no longer take your insurance (they do have to typically provide 90-120 days notice and offer to refer you). Unfortunately this can happen for many reasons- mostly we see this because the reimbursement rate is insufficient. 
  • Insurance companies can access your records AND they can find that you do not need services any longer. A therapist has to reflect in their notes that you meet a certain criteria for that particular service (including how long that service lasts) . 
  • Specialization: Insurance can and does restrict against certain types of therapy. If you are looking for someone who specializes then you need to know what your insurance plan will/will not cover. 

 

Other Things to Consider

When we talk about understanding your benefits, here is a list of questions I normally have my clients find out. 

  1. When does my plan start and stop. This is important in the event that your company changes plans, your out of pocket expenses will change, etc. 
  2. Are there any exclusions? An exclusion could be they don’t cover family therapy or they don’t cover ADHD. (Yes – insurances can do this). We also see a lot of exclusions for ABA services (we don’t provide this at Turning Stone Counseling) which is used alot for Autism; testing exclusions and certain types of therapy like Neurofeedback, TMS, etc. 
  3. Are there any restrictions on services provided and/or how long? Many times insurances reflect the same sentiment which is “it’s based on medical necessity”- this just means that they want the documentation to reflect why we are doing what we are doing. 
  4. Do you have more than one insurance? If Yes- know that many practices will not do secondary billing. First off – it’s truly a pain. Unlike a medical practice, mental health practices don’t have the time or staff to research who’s primary or waiting for the claim to be paid out by the first plan then bill the second one. Be prepared to pay the out of pocket expense up front and then ask for a superbill so you can submit it for the secondary reimbursement. 
  5. Do you have Out of Network (ONN) benefits? So important to ask this- for many reasons if the practice you are going to no longer accepts your insurance you have that option to now do ONN. If its recommended that you receive additional services- this can be helpful. 
  6. If I am using my FSA or HSA card- can I get a statement? Absolutely- if you need a statement, every practice’s accounting software should be able to provide you with this document to submit. 
  7. What’s a Superbill? – This form is basically an invoice for your services but it includes important information that you can use to be reimbursed by your insurance plan. 

Let us know if we can help you in any way as you navigate insurance.

Check us out at www.turningstonecounseling.com