The Affordable Care Act (also known as “Obamacare”) has been around now for a few years. While there are yearly changes in the plans available, it also means a growing number of people have some type of health insurance. In NC, if you got insurance from the “market place”, it means you either got a plan from BCBS, Coventry or United Health Care (UBH). In many cases, unless you got a higher level plan, you have a large in network and out of network deductible to meet before insurance will cover health care services (except those services deemed “preventive”). This means that while your care and diagnosis will be reported to the insurance company as a “pre-existing condition”, you will be essentially paying out of pocket with little to no insurance coverage, depending on your deductible. In these circumstances, it may be better to pay out of pocket and not submit these to apply to your deductible. If you pay out of pocket & do not request coverage, reimbursement, or for payments to apply to your deductible, HIPAA prevents insurance companies from accessing your information. At our Durham, North Raleigh mental health practice, protecting your rights and privacy, as well as your eligiblity and insurability is vital to us.
Durham & North Raleigh Mental Health Services Insurance Benefit Info
What You Need to Know About In & Out of Network Benefits
Some Important Information About Out of Network Benefits
As mental health services insurance reimbursement rates to providers have been dramatically lowered, client copays have continuously and dramatically risen (leaving the client to pay almost 100% of services & insurance paying nothing), many of us have chosen to leave insurance networks. We have also made this decision for clinical reasons, because what insurance allows for does not always equal good care. For example, because insurance uses a medical model for covering services (i.e., there must be an identified client who has a diagnosed condition and sessions are aimed at treating that diagnoses) insurance does not cover parenting sessions (without the child present), couples counseling and marital therapy, conjoint sessions (adult family members, friends), or sessions that exceed 60 minutes. Not involving insurance, means that we are in charge of what you need, not what the insurance will allow. Also, all of this is private, so we don’t have to diagnose you and therefore giving you a pre-existing condition that impacts your insurance rates. So, for example, if you don’t have a diagnosable condition, but just feel you need someone to talk to about relationship concerns and a 75 minute session is most helpful, we are free to do that. However, based on insurance medical necessity expectations, this would not be allowed. So, excluding the insurance company means we can meet your needs, not the insurance company’s.
You can check your Out of Network Benefits (OON). Insurance companies prefer to give this information to the member, rather than a provider who is not in their network, so we encourage you to contact your insurance company. However, we’d be happy to help you with what questions to ask and understanding the information provided. As insurance copays continue to rise, it is possible that your OON benefits are not that different from your In Network Benefits. Sometimes, there is a deductible to meet (which can be the case with In Network benefits as well, depending on the plan) and many times there is not. Usually, OON benefits will cover a percentage of the “allowable rate”. Unfortunately, insurance companies will often not share what this allowable rate is. However, it is usually a range (with insurance reimbursement rates at the lowest end of these) called “reasonable and customary” or “usual and customary” rates. Many plans will cover 60-80% of these reasonable and customary rates, but we often have to guess what that range might be. So, if we charge $100 and insurance allows for up to $90 for that service and they reimburse at 70% of up to $90, after reimbursement, you would have paid $37 for the session.
How this works is that you pay us whatever fee we agree on (To see our rates if paying for counseling outside of insurance, click here), we will give you a receipt to submit to insurance and they will reimburse you directly. If you would like us to file the claim for you, there will be a $7.00 charge per claim to cover the costs of our billing company’s services. Just let your therapist know if you would like us to do that. However, we have found that when we submit the billing, that often this confuses the insurance company and they may randomly reimburse us, delaying payment to you. Usually it takes about three to four weeks for you to get reimbursement directly from the insurance company.
When providing Durham, North Raleigh mental health services, we welcome seeing you outside of your insurance, especially to ensure your medical records are kept private and to allow us to decide what is best for you, not the insurance company. New HIPAA regulations specifically allows for the right of patients to deny access to their medical record if they pay for the services/treatment out of pocket. To see our rates if paying for therapy services outside of insurance, click here.
Click here for more information about fees for our Durham, North Raleigh mental health service insurance and fees. Or call us for more information about Durham, North Raleigh mental health service insurance coverage and to compare paying out of pocket for counseling vs using insurance benefits.