Getting reimbursed by your insurance

   

      1.     If you are curious how fees are established and how they correspond to the local area and to the “Usual, Customary, and Reasonable” (UCR) fees that insurance companies reference, check out the website:  Fair Health Consumer at www.fairhealthconsumer.org.  There are few regulations for insurance companies when determining what they consider to be usual fees, and their methodologies vary considerably.  However, as an informed consumer, you can use the website to find out!

 

     2.     Look up various services for “Out of Network” (OON) providers in our area (e.g., psychotherapy is code 90834, psychoanalysis is 90845).  My fees are established on the basis of the website referencing the local area UCR.

 

     3.     Call your insurance company and ask them what your coverage for Mental Health service is (both for fees and sessions; you might also ask them for a pre-authorization).  Typically, the company will cite their reference UCR fee or perhaps a percentage of that fee, or may not disclose anything at all.  Ask the insurance company if the fee for service is above the UCR they are referencing (typically they will only answer yes/no, but not disclose their reference fee, which they will tell you is ‘proprietary information’ and refuse to disclose it; this means that the fee is perhaps as little as $1 over their reference fee.  The insurance companies are in business and aim to maximize profits and so attempt to reimburse as little as possible).  Once you have information as to your coverage, you can calculate how much of the agreed upon fee you will be reimbursed.  Ask your insurance company how they reimburse and how quickly you can expect it.

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     4.     For our work together, the fee is due by cash or credit card at the beginning of the session.  I can provide to you a statement of fees paid that you can submit to the insurance company for reimbursement (once or twice per month, by request).  Typically the insurance company will require you to also include one of their claim forms along with the statement so that they can reimburse you.  For example, if your fee is $250 for a session and the insurance company will cover 80% of the fee, then your reimbursement amount would be $200, less whatever copayment/coinsurance your company requires. 

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     5.     Sometimes you will have an annual deductible that must be met prior to you being reimbursed.  For example, if your deductible is $6000 per year, then the first $6000 of fees for all your healthcare would not be reimbursable by the insurance company, but will be accounted for by your submissions to establish evidence of payments made toward your deductible.  Once your deductible is met, then your insurance company will begin to reimburse you.  

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