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Insurance reimbursement: let's break this down
I am human too. As someone who has been on the client side of out of network providers, I empathize with cost needing to be filtered into consideration. I hope this guide can assist you in gaining a clear understanding of how your insurance can or cannot assist you in any manner. Although I do not directly bill insurance, there is a possibility your insurance reimburses a certain percentage of our work together or follows another helpful protocol. This guide aims to give you a sense of control and empowerment, as the healthcare system can be overwhelming.
Call the number on the back of your insurance card for the Benefits Department. Write down every answer you receive. Ask for explanations of anything you don't understand, as the system can be complicated and use fancy wording. Ask to speak to a supervisor if you are not happy with the answers you are getting. You'll need careful records later if the company fails to follow through with what they've told you.
Many insurance companies will reimburse a percentage of the total fee paid. For example, your company may reimburse you 80% of the total fee paid, or $100 for a $125 individual session. Other companies will substitute the $125 fee for what they deem appropriate, regardless of what you paid. For example, your company may say that they will reimburse you 80% of the “allowed amount” of the fee. You paid $125 or an individual session, but your insurance company only allows $60. Therefore, you will be reimbursed 80% of $60, or $48. They may try to withhold this information from you and can legally do so. Ask to speak to a supervisor and say that you cannot plan your medical expense budget without this number.
1) What is your name and extension number?
2) Does my policy cover Out-of-Network, Licensed Clinical Social Workers?
3) My therapist is willing to provide a statement/superbill of Session Dates Attended, the CPT code, and the Diagnosis. Is this acceptable to the insurance company?
4) Does my policy cover 60 minute Individual Therapy (CPT 90837)?
5) What mental health Diagnoses are NOT reimbursable?
6) How many sessions are covered per year?
7) What is the Lifetime Maximum for mental health benefits?
8) What is my Out-of-Network Deductible?
9) What is the Allowed Amount of the fee? My therapist's individual session is $125 for CPT 90837.
10) What percent of the Allowed Amount will be reimbursed?
11) How do I file a claim? Many companies now make it very easy by providing a link to quickly upload your statements or receipts.
Insurance reimbursements will vary from month to month:
At the beginning of your therapy, there will be a wait until your insurance company begins to pay your benefit.
In January of each year, you will not get any money back until your deductible is met. If you apply other family medical expenses to your deductible, you will start getting benefits sooner, and more of your therapy will be paid for.
Toward the end of the year, your insurance reimbursements will stop if the number of sessions is limited.
Your out-of-pocket medical expenses can be minimized if your employer offers a pre-tax medical "flexible spending account."
Ask your accountant about taking a medical tax deduction for psychotherapy.
You may save money with an insurance plan that has a higher premium, but better benefits for out-of-network therapy (called Preferred Provider Organization, or PPO).
In January 2010, new legislation requires many insurance plans to provide the same benefits for mental health as for physical health, with many of these limits removed—very good news!