Posted by: counselorcarmella | January 27, 2014

Some 411 About Counseling and Insurance

January is a time when insurance plans change, deductibles start over, and clients are often unhappy with what our billing coordinator tells them regarding their insurance coverage. A lot is changing with Obama Care, parody laws, the new diagnosis codes coming out, and more and more people not having insurance coverage for health care or having inadequate or very limitted coverage. Mental health coverage is every bit as important as the coverage you have to see your primary care doctor, to go to the hospital, or when you’re referred to a specialist. The cost of services people have to pay for out of pocket can limit their seeking out needed care and can create an additional financial stressor.

In a perfect world, we’d all have adequate and affordable health insurance coverage, the insurance companies would have good working relationships with all qualified providers, services would be covered based on if the provider says they’re needed, and the policy holder gets what they need from the coverage they have. Deductibles don’t exist and copays are never more than $20. Simple as that. No muss, no fuss. Sometimes, thankfully, it is that simple or close enough so that its manageable.

As we’re all very aware of by now, though, this is not always the case. Many policies do provide mental health coverage but its not automatic and its not guaranteed. There are limitations. How much clients have to pay for copays or deductibles varies a lot and you may not be able to see the counselor you want to see, or see them as many times as you want to. Just because your friend or family member pays this and sees so and so doesn’t mean that’s going to be how it goes for you, even if you have insurance with the same company. It can be confusing and frustrating for everyone. We know. We empathize. We’re dealing with the same things personally and professionally, too. So are lots of other clients/patients besides you. This is not personal. Its not that insurance companies are evil; they just have certain rules. Its a catch 22, a double edged sword, a blessing and a curse. Insert cliche here. I don’t have solutions or answers. All I can offer are some comments based on what I’ve learned from the people who handle this stuff at my office and from other counselors. Let me see if I can make you more confused.

First of all, its your policy. Know about it. Read the handbook. Call the customer service number on your insurance card and ask questions. Consult the website. There are FAQ sections, lists of providers, and other info about your benefits, copays, etc. that you have access to as a policy holder. Don’t make assumptions and be surprised when you show up for an appointment somewhere. Our billing people will check your policy and bill your insurance company an dall that, but you can also find things out for yourself. You can and you should.

If you get something in the mail or are told something that doesn’t make sense, politely ask for clarification. Ask nicely but clearly and engage in dialogue that is pleasant and productive. If someone at a medical facility or an insurance company tells you something about your insurance you don’t like, getting mad with them and making a jerk of yourself is not going to make them want to try and help you. If you need to cool off and then call back with more questions or to continue the conversation, that’s fine. Disengage and try again when you’re in a better frame of mind to listen and take in information.

If you wish to use your insurance, finding someone who is pannelled and in good standing with your insurance company is the easiest thing to do. Keep it simple and go this route if possible. Insurance companies have lists of providers who are pannelled (aka in network) with them. Most counselors will tell you which insurance companies they are pannelled, or in network, with.

All insurance companies have standards in terms of education and licensure. They want to be sure they are referring to, and working with, providers who are qualified to treat people with mental health issues. This helps keep the public safe from a lot of snake oil salesmen who offer services under various other titles but can restrict the ability of newly licensed counselors to gain experience and decent caseloads. Someone may not be taking your insurance yet but may be in the process of being pannelled and will be able to very soon. The process of submitting paperwork and getting approved for pannels takes time. This is true for those who are newly licensed and for counselors who are relocating to a new state or going from a public agency to a private practice. It often seems to take longer than it should from our perspective and I don’t know exactly why but it can take several months or longer in some cases once the insurance company has all the paperwork.

Also, for complicated reasons, some companies have decided only certain types of licensed mental health professionals are “acceptable” to them. They don’t want counselors with these letters after their names, they want these other letters. They may only want PhD psychologists or MD psychiatrists, for example. Some insurance companies say they already have enough providers in a certain area and aren’t currently allowing new folks to apply to be on their pannels. Many private practices don’t accept Medicaid or MediCare, for example.

Some counselors aren’t pannelled with any of the insurance companies because, frankly, insurance can be a hassle. They possess the right licenses and educational qualifications, but don’t want to deal with the paperwork, diagnosing, limits on numbers of sessions, types of therapy that can be used, and so on. All those things are part of what comes with dealing with insurance and some folks choose not to deal. We’d all love to operate this way, but the reality is that most of us could not survive on fee for service clients. These are the people who can pay $70 to $120 an hour out of pocket for counseling on a regular basis and that’s not most people. Many of us don’t want to just serve a population that can pay out of pocket that way and can’t reduce our fees enough for others and stay in business. A counselor who does not take any insurances may be able to recommend several colleagues who do.

Once you find a counselor who takes your insurance, they have to get an authorization to see you for the first time. Then, after that first session, they have to provide the insurance company with a diagnosis code. This is a code that says why it is “medically necessary” for you to receive counseling services. This means your insurance company is going to know what the counselor believes you have, such as major depression, geneeralized anxiety, bipolar disorder, or whatever. A diagnosis is made based on your symptoms, how long you’ve been having them, and how much of a problem they are. Again, the term we’re hearing more and more is “medical necessity.” This means a client has to have symptoms that interfere with daily functioning, or that cause pretty serious distress or impairment. There have to be specific symptoms. They have to be causing problems at work, home, or school.

Your insurance might not cover something that just seems like prevention, supportive counseling, or for someone to “coach” you through a little rough patch. Those sorts of counseling can be very helpful, but they may not be considered “medically necessary.” We’d like to be able to help you work through something stressful that isn’t a big problem yet but could become one. We want to help you to function as well as possible and to help you have the healthiest possible relationships. We want to be able to be an additional support during a stressful time. We’d like to give you a few pointers about this or that, to offer some helpful feedback to get you headed in the “right” direction. We like being a neutral third party who can make suggestions or offer a different perspective for you to consider. We welcome opportunities to just offer reassurance that what you’re going through is “normal” given the phase of life you’re in. We can do that, but your insurance might not cover it. If its not a huge problem yet, meeting with a counselor just a few times may be all you need so paying out of pocket may be worth it.

If we tell you we can’t give you a diagnosis that your insurance will cover, we’re not trying to avoid using your insurance. We can’t label clients with something they don’t have. For one thing, that’s insurance fraud. Fraud is a big deal. For another thing, its unethical. A diagnosis becomes part of a client’s health reccord and we may be asked at any time to explain why we’ve given someone a particular diagnosis. Sometimes, what we’ve diagnosed you with is something your insurance company won’t cover. We have a big problem with companies not liking it if we diagnose someone with Attention Deficit Disorder, for example. They also don’t like to cover Axis II disorders. These are the personality disorders. Other times, clients are coming in because of life or relationship stressors. We can list the stressors, but they aren’t going to be covered diagnoses. Many policies don’t cover marital or family counseling. Some of this will be changing based on how the new diagnostic manual is structured. Don’t be mad at us. If it frustrates you, take it up with your insurance company. We have to follow the guidelines they set for us. It frustrates us a lot, too.

If your counselor takes your insurance and the insurance company covers what your counselor diagnosed you with, there are other limitations, as well. Most of the time, you will have a co pay or a deductible that has to be met. Most co pays are around $25.00, but they can be more and they can be less. Deductibles are what you have to pay out of pocket before the insurance will start covering all or part of your counseling. They range from none, to several hundred, to separate for each family member and for mental health vs medical. Some are very high. Second, they usually have a limit on how many sessions they’ll allow you to have. Twenty per year, for example. Clinicians can request some additional visits, but sometimes, it just is what it is. That’s the coverage you’re allowed within the policy.

If your counselor takes your insurance, they’re going to do their best to make best use of your coverage. A lot of times, it works out and clients can get what they need from counseling, even if its not 100% ideal. You can handle the copay, what you need is covered, and you and your counselor can work with the number of visits you have. A lot of counseling centers have folks who do our billing and collections. They know how to work with the insurance companies an they know how to make sure the right documentation is provided by the counselor. I’m very thankful for other people who handle the insurance stuff at my office. Some counselors do all this themselves. This means filing the paperwork needed each time you come in, but it also means doing the paperwork that has to be done every couple years to stay credentialed. There is different paperwork for each company. My heart goes out to those in solo practices who choose to do all this themselves.

If you really REALLY want to see a counselor who is not pannelled with your insurance company, because maybe you changed insurances while already seeing a counselor or need a certain type of specialist and the one specialist in that thing in your area is covered under your insurance, there are a couple options worth considering. You can ask your insurance company about whether out of network benefits are available. This means the insurance company will provide a certain amount of coverage for someone who is not pannelled with them. They may not be the same benefits as those provided for counselors that are in network. Sometimes it is possible to work out a “single case agreement” between the counselor and the insurance company. It never hurts to ask.

Another option is that you can try to get your insurance company to reimberse you directly. Some counselors will sign forms or provide information to help with this process. Not every insurance company will do this and not every counselor will provide any paperwork so ask and know this varies a lot.

If you are uninsured, your deductible is too large, or you need a counselor who will see you on a sliding scale fee basis for other reasons, there are options. Counselors in your community will know more specifically what those options are and what to suggest. Your pastor or doctor may be a good resource in this regard, as well. Your workplace may offer a certain amount of free or low cost counseling. Ask and be open to options, even if those ideas wouldn’t be your first choice. See my next post for additional info on this.

Ultimately, if you truly need counseling or psychological help, you can’t put a price on your mental health. Untreated conditions often get worse, which means more extensive treatment, more disruption to your life and negative impact on your job and loved ones, and more risk that you are going to have bigger problems. If you know, or if loved ones are telling you repeatedly that you need help, listen, be humble, and be willing to ask for the help you need.


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