Calling Your Insurance Company

October 30, 2009 by Kathie Keeler
Filed under Therapy 101

Being an educated consumer can save you lots of money!

Of course, you don't have to use your insurance. We're glad to accept credit or debit cards or cash for a discounted rate. For those with a high deductible paying the cash discount could be a way to keep therapy affordable without the hassle. But, if you want to use your insurance, it pays to educate yourself. We bill dozens and dozens of different plans every year and are happy to do so as a courtesy to you. Please understand, however, that we offer no guarantee that your insurance company will pay. That is between you and your insurance company.

We are happy to bill for you. We know a lot about insurance companies in general. We may not know about yours. There are just too many out there. In addition to that , plans change, rules change, and we're not informed of those changes--you are. We expect that you do your part by being an educated consumer, asking questions if you don’t understand, and communicating with your insurance company should a problem arise. Many, many clients have saved themselves hundreds of dollars by understanding their insurance plans and taking the trouble to authorize their mental health visits ahead of time.

How to educate yourself

Navigating through the health insurance industry is a challenge. It is even more of a challenge if you do not understand the language that is used by those in the industry. So, to help you out, we are happy to tell you how to ask about your mental health benefits. We really do want you to be an educated consumer. Here’s what to do:

Look at your insurance card.

The “member ID” is on the front. Have the card in hand when you call your insurance company.

Turn your card over.

On the back you’ll see various numbers. Perhaps you’ll see an 800 number for customer service. More specifically, if your insurance company lists an 800 number for “behavioral health” or “outpatient mental health services,” that’s the number you’ll want to call.

When you call the number, you’ll reach a representative who will ask you what you want.

Ask ALL of these questions.

“I’m calling to determine eligibility and benefits for outpatient mental health therapy with Kathie Keeler, licensed clinical social worker.” They will ask you for your name, your member ID (or social security number), and date of birth. After they have determined that you are who you say you are, be sure to ask the following:

Do I need a pre-authorization number prior to seeing someone?

Do I need to keep track of the number of visits? (Usually you do.)

Do I have a copay? How much is it?

Do I have co-insurance? (This is a cost-sharing arrangement between you and your insurance company in which you pay a percentage of each visit.) What is the percentage? This is usually true for some Blue Cross/Blue Shield plans, which have both a copay and co-insurance. (It gets tricky because you have to pay both a percentage of each visit as well as a copay each time.)

Do I have a mental health deductible? If so, has it been met this year? Some companies have a separate mental health deductible. So, even if you've met your medical deductible, it doesn't necessarily mean that you've met your mental health deductible. If it hasn’t been met, you’ll want to find out what you will need to pay at the time of the visit. You can do this by asking the following.

What is the contracted reimbursement rate on my plan for an initial visit, billed under the CPT code 90801?

What is the contracted reimbursement rate on my plan for subsequent visits, billed under the CPT code 90806?

More information you may need to know:

If your insurance company only gives you five visits, you have the obligation to count your visits so that you don't go over your allotted amount. This is your job; not ours.

Some companies will want to know the date and time of your visit prior to giving you a pre-authorization number. They ask this to determine whether or not the therapist has availability. Give them a date and time.

Some insurance companies will want to know why you want to see a therapist. They ask this to determine whether or not the problem is “medically necessary." Most insurance companies will only cover medically necessary diagnoses, such as depression or anxiety. You have the right to privacy. You don’t need to tell your story to an insurance company representative, and probably shouldn’t.

Be aware that insurance companies can only stay in business by making a profit. They do this by saving money. And this is where the horror stories begin. What you say can used against you.

What NOT to say:

“I’m court-ordered to therapy."
“I want marriage counseling.”
“My child has AD/HD.”
“I’m just stressed and want to talk to someone.”
“I need some anger management classes.”

Although all of these things may be true and legitimate, your insurance company could use this information to disallow visits. Please talk to me first.

You will be given a diagnosis.

Please be aware that your insurance company cannot be billed without a legitimate "medically necessary" diagnosis. This diagnosis is part of your permanent record--not only with the insurance company, but also with the Medical Information Bureau (MIB) The MIB is a central database of medical information shared by insurance companies. About 600 insurance firms use the services of the MIB primarily to obtain information about life insurance and individual health insurance policy applicants. When you apply for life or health insurance, your insurance company may look for codes in the MIB that indicate you've had a problem in the past. The MIB is not subject to HIPAA. So, even though our records are confidential; your insurance company will likely forward the diagnostic codes to the MIB. Not only can insurance companies deny applicants based on prior treatment, certain government positions may require an explanation of why you were treated for a medically necessary diagnosis--even many years previously.

Share and Enjoy: