Where do I obtain information about my health plan?

Each subscriber in a health plan receives a policy handbook upon signing up of his or her insurance. If you receive health care benefits through your employer, they can provide you with a copy. Covered benefits vary from policy to policy and from insurance carrier to insurance
carrier. It is important that you read through your most recent handbook and know your policy, making notes of any questions you may have.

I have questions about my policy – where can I get them answered?

If your insurance is provided through your employer, the human resources staff can assist you. If you purchased your insurance, the agent who sold you your policy should be able to answer your questions. Or you may contact your insurance carrier directly at any time. Typically, the
contact information is listed on the reverse side of your insurance card.

How will I know if my policy changed?

Your insurance carrier must notify you in advance of any changes in your policy. It is your responsibility to keep current of those changes.

Isn’t my therapist responsible for knowing my benefits?

No. Medical and Mental Health Providers are not responsible for knowing your policy and what is covered or not covered. Patient benefits vary widely with hundreds of different plans available in today’s market. Physician’s offices and Therapist’s bill your insurance as both a courtesy and convenience to you as a patient. However, your benefits are your responsibility to know and understand.

What does participation provider or preferred provider mean?

This means that your medical care provider or therapist has a contract in place with your insurance carrier to provide health care services to you for a pre-determined fee schedule. Deductibles and co-payments still apply.

How does insurance work at A Peaceful Balance?

Since the Therapists at A Peaceful Balance work independently from each other, each therapist is in network with different insurance companies. Check out the About Page to see which provider accepts your insurance. If you do not see your insurance listed, that therapist is considered out of network. For out-of-network therapists, you as the client can contact your insurance carrier to ask if you have “Out of Network” behavioral health benefits. If so, ask them what the reimbursement would be for you and what the procedure is for you to submit to them for reimbursement. Clients would then pay the provider out of pocket at each session. A receipt will then be given to you to submit for reimbursement with your insurance plan. For more information about getting fair and accurate coverage for your psychotherapy, read the article below:

Getting Fair and Accurate Insurance Reimbursement for Your Psychotherapy

The process of getting reimbursed by your insurance may be much easier than you think. For a better understanding and guidance, read the information below. Knowledge is power, so it’s good to know what to expect as reimbursement for psychotherapy and how to make sure your insurance company is handling your reimbursement fairly and accurately according to your insurance coverage. I hope you find it helpful.

1. First, get informed!

Here’s an important thing everyone with insurance needs to understand: Insurance companies use some “creative” ways to determine the basis of what they’ll cover. It’s not just that your plan says it’ll cover, say, 80% of the cost of psychotherapy — it’s 80% of what they say psychotherapy costs. That’s an important number.

They get crafty about how they come up with that number, and even what they call it. Sometimes they use something called Usual, Customary, and Reasonable (“UCR”). Or reasonable market value… a number they can basically just make up. Or they’ll use a percentage of Medicare rates as the basis for how much they’ll pay — even if you aren’t eligible for Medicare, which is specially negotiated insurance for people 65 or older, younger people with disabilities. Keep in mind that they use that number to calculate your reimbursement. For example, if your insurance plan says it covers 80% of psychotherapy fees, it really means they’ll pay 80% of what they say the typical fee for psychotherapy is. The catch is that there are very few regulations for how they determine that number. And, they usually won’t tell you (their customer!) what that number even is — calling it “proprietary information.”

Look up the Typical Provider Charge

Thanks to numerous class action lawsuits, and legislative work on healthcare laws, there’s a consumer rights website where you can see what an objective source says the typical fees are in your area. The site is Fair Health Consumer (https://www.fairhealthconsumer.org/) and here’s how to use it to look up the Typical Provider Charge (Fair Health’s term for UCR) for psychotherapy in your area:

1. Enter the Zipcode of your therapist.
2. Enter the procedure code; 90837 is the procedure code for individual outpatient psychotherapy, 60 minutes, or you can ask your therapist what code they’ll use.
3. Click “See Out-of-Network Reimbursement”.
4. Scroll down to “Cost Breakdown” (ignore the first few rows you see on the page — those include other charges like hospitalization).

There you have it! Now you know the real typical cost for psychotherapy in your area, and you’re armed and ready to call your insurer.

2. Call your insurance company

When you call, they’ll first let you know what your insurance plan covers in general terms — for example, 80% of “the UCR.” (So, for example, if your insurer considers $125 to be the UCR for psychotherapy, and you have 80% coverage, they’ll cover $100.) Now you’ll want to ask about what to expect for reimbursement for psychotherapy. For example, if you were to call about reimbursement for psychotherapy, you’d tell your insurer this information:

1. You’ll be submitting claims for “Individual Psychotherapy, Outpatient, 60 minutes also referred to as CPT code 90837.
2. My current fee for CPT code 90837 is $125.00 (use this number when calling as it is my “usual and customary fee”.) My Zip code is _____ (reimbursement varies based on location).
3. My provider is a Licensed Independent Clinical Social Worker who is not a participating provider (meaning she has chosen not to have a “contract” with any insurance companies).

Then ask them if your therapist’s fee is within the range of what they use to determine reimbursement. If they say anything, they’ll typically only say either “yes” or “no”. If they say no, or that they can’t tell you that, you can tell them you’ve used the Fair Health Consumer site to look up the Typical Provider Charge for psychotherapy in your area, and that the amount is $_____ (whatever you’ve found using Fair Health). Then ask them if that figure is what they use to determine reimbursement — and if not, why not!

3. Ask your psychotherapist for help and guidance

Clearly, insurance companies prefer to skew things to their advantage, not to the advantage of patients. Your therapist might be able to offer some general guidance as to the ins and outs of getting the reimbursement you’re due. You can also ask for help from the Human Resources if you have insurance through your place of employment. They should be able to assist you in getting the benefits that you are entitled to through the insurance company.

Telehealth Therapy

The therapists at A Peaceful Balance offer both in-person and telehealth therapy. Telehealth can be a helpful option, but there are some restrictions regarding delivering telehealth services. If you are interested in the telehealth therapy, talk to the therapist to see if it could be an option for you.

Self-pay options are available for all services. Why self-pay for your mental health care?

→ Choice. The relationship with your therapist is important. You do not have to rely on your insurance company to tell you who is available to you.
→ Privacy. Your information stays private without correspondence between your therapist and the insurance company.
→ No diagnosis. Insurance companies require a diagnosis. Self-pay gives you more freedom over your treatment without the need to assign a diagnosis on your health record.
→ No Maximum. There is no limit on the number of sessions you are allowed to attend. FORMS FOR PAYMENT – Please see the provider’s page to see which types of payments are accepted by each provider.