Navigating Mental Health Expenses: To Insure Or Not To Insure?

Whether or not you should submit psychological bills to your insurer depends on a number of factors. If you are a mental health professional, you may want to submit bills to insurers to receive reimbursement for your services. However, the complex rules and regulations of the insurance industry can make successfully submitting claims a difficult and frustrating process. If you are a patient, you may be responsible for submitting a claim for reimbursement from your insurance company, depending on whether your therapist is in-network or out of network. In either case, it is important to be aware of the specific policies and requirements of the insurer in question, including deadlines for submitting claims and requirements for pre-authorization of certain services.

How to submit a claim

The process of submitting a claim for psychological bills can be challenging, but here is a detailed guide to help you navigate it:

Step 1: Collect Itemized Receipts and Bills:

Obtain an itemized bill from your psychologist or therapy provider. This bill should list each service provided, along with the associated costs and special codes required by the insurance company for reimbursement. Contact your provider and inform them that you are filing an insurance claim to receive this information.

Step 2: Obtain and Complete a Claim Form:

Acquire a health insurance claim form, which can often be found on the insurance company's website or brochure. This form will include sections for personal information, insurance details, the reason for your visit, and provider information. It is crucial to fill out all the necessary fields accurately and provide any additional information requested by the insurance company.

Step 3: Make Copies of Your Documents:

Before submitting your claim, make at least one copy of your completed claim form and all the supporting documents. This step serves as a preventative measure in case of any complications or if your claim is lost during the process.

Step 4: Review, Call, and Submit Your Claim:

Thoroughly review your claim form to ensure all fields are completed and necessary attachments are included. Then, contact your insurance company to inform them that you will be sending in a claim form. During this call, inquire about any additional documents they may require and the expected timeframe for claim processing and reimbursement. After confirming that you have all the necessary information, send your claim form and supporting documents to the insurance company using the provided address or email.

Step 5: Follow Up on Your Claim:

Keep track of the date when you submit your claim. If you do not receive a response or reimbursement within the expected timeframe, follow up with the insurance company. Make sure to document the details of your communication, including dates, times, names, and job titles of the individuals you speak with. This creates a paper trail, which can be useful if further issues arise.

Additional Considerations:

• Deadlines: Note that different insurers have varying deadlines for submitting claims. Private insurers typically have shorter deadlines, while Medicare and Medicaid allow up to 365 days from the date of service. It is essential to check your insurance policy for specific guidelines.
• Reimbursement Timeframe: Reimbursement times can vary, but it typically takes at least 30 days from the date the insurer receives the claim.
• Provider Network: If your psychologist or therapist is not part of your insurance company's provider network, you may need to pay out of pocket first and then submit a claim for reimbursement.
• Diagnosis Codes: Be prepared to provide specific diagnosis codes on your claim form. These codes are typically provided by your therapist and are necessary for accurate reimbursement.

What to do if a client doesn't inform you about changes to their insurance plan

If a client doesn't inform you about changes to their insurance plan, it's important to take the following steps to ensure accurate billing and reimbursement:

• Contact the insurer to verify the client's coverage details and determine if there have been any changes to their plan. This step is crucial to avoid wasting time on rejected claims.
• If the client's coverage has changed or lapsed, reach out to the client to obtain their updated insurance information. If they no longer have insurance, discuss alternative payment options and try to get payment from the client directly.
• File a claim with the new insurer if the client has switched insurance providers.
• Stay informed about the client's insurance coverage by evaluating their insurance plan before each visit, if possible. This proactive approach can save time and hassle in the long run.
• Maintain open communication with your clients and request that they notify you if they switch insurance providers. This helps to ensure that you have the most up-to-date information and can bill the correct insurer.
• Familiarize yourself with the billing codes and procedures specific to mental health services. This includes selecting the appropriate Current Procedure Terminology (CPT) codes and diagnosis codes for each session.
• Stay organized and maintain proper documentation for each visit. This will help support your billing claims and facilitate prompt reimbursement.
• Be mindful of deadlines and payment schedules. Each insurer may have different timelines for submitting claims, so stay on top of these deadlines to avoid delays or rejections.
• Establish clear policies for when insurance denies a claim, including determining financial responsibility and following up with the client or insurer.

How to get credentialed with insurance companies

The process of getting credentialed with insurance companies can be confusing and overwhelming, especially for those new to private practice. Credentialing is a process used by insurance companies to verify your education, training, and professional experience, and to ensure that you meet their internal requirements for serving as an in-network provider. Here are the steps to get credentialed with insurance companies:

• Prepare for Credentialing: Before starting the credentialing process, it is important to have certain things in place. This includes establishing a business entity (LLC, S-Corp, PC, etc.), obtaining a federal tax ID, getting professional liability insurance, obtaining your National Provider Identifier (NPI) number, being fully licensed in the state where you will provide services, and creating a profile with CAQH.
• Research Insurance Companies: Identify the insurance companies you want to be credentialed with. Consider asking peers or billing professionals in your area about which insurance companies are most popular with patients. Major national plans to consider include Aetna, Blue Cross Blue Shield, Cigna, United Healthcare, Humana, Medicare, and Medicaid.
• Apply to Become Part of the Insurer's Provider Panel: Contact each insurance company and express your interest in becoming an in-network provider. Most insurers will provide an application on their website, which you will need to complete and submit.
• Complete the CAQH Application: Many insurance companies require completion of the Council for Affordable Quality Healthcare (CAQH) application as part of their credentialing process. You will typically need to apply to the insurance company first and receive a CAQH number before you can complete the CAQH application.
• Follow Up: The credentialing process can take several months, and you may need to provide additional information. It is important to follow up regularly with the insurance companies to ensure that your application is progressing and to address any issues promptly.
• Review and Sign the Contract: Once your application is approved, the insurance company will send you a provider agreement that outlines the terms of your participation, including reimbursement rates. Carefully review the contract and, if you are satisfied with the terms, sign and return it to the insurance company.
• Stay Up to Date: Maintain your credentials by regularly updating your CAQH profile and re-attesting your information on a quarterly basis. Keep track of any changes to your practice information, such as address or phone number, and inform the insurance companies as needed.

How to check eligibility and benefits for mental health

Checking eligibility and benefits for mental health services can be a complex process. Here is a step-by-step guide to help you navigate it:

Step 1: Understand the Basics of Mental Health Benefits

Before initiating the process, it is essential to understand the basics of mental health benefits. Mental illnesses are considered disabilities under the Americans with Disabilities Act (ADA) and the Social Security Administration (SSA) if they impact an individual's ability to work or perform daily tasks. The SSA defines disability as the "inability to engage in any substantial gainful activity (SGA) due to a mental impairment lasting or expected to last at least 12 months."

Step 2: Identify the Type of Insurance

The eligibility and benefits process may vary depending on whether you are dealing with private insurance, government-sponsored insurance (such as Medicare or Medicaid), or disability benefits. Each type of insurance has its own set of rules and requirements.

Step 3: Gather Necessary Information

To check eligibility and benefits, you will need to gather specific information. This includes personal information such as your full name, date of birth, address, gender, and phone number. Additionally, you will need insurance information, including the subscriber ID, customer service phone number, and insurance card details.

Step 4: Contact the Insurance Company

The next step is to contact the insurance company. You can do this by calling the customer service phone number on the back of the insurance card. Have all the necessary information ready before making the call.

Step 5: Verify Eligibility and Benefits

When speaking with a representative from the insurance company, verify the mental health outpatient provider eligibility and benefits. Provide them with your National Provider Identification (NPI) number and Tax ID, and ask if you are in-network. Also, give them the patient's name, date of birth, and subscriber ID. Ask about the patient's deductible, copay, and coinsurance, and take note of this information. Additionally, inquire about the claims addresses and any other relevant details.

Step 6: Understand the Coverage Limits and Restrictions

It is important to understand the coverage limits and restrictions imposed by the insurance company. Ask about the number of sessions covered, the length of each session, and any pre-authorization requirements. Inquire about the reimbursement rates and whether there are any specific conditions or diagnoses that are covered. Understanding these details will help you determine the extent of coverage and any potential out-of-pocket expenses.

Step 7: Follow Up and Confirm

After gathering all the necessary information, confirm the details with the insurance company. Ensure that you have a clear understanding of the patient's coverage, including any deductibles, copays, and coinsurance. Ask about the process for submitting claims and reimbursement, and make sure to take note of any deadlines or time limits for filing claims.

Step 8: Stay Informed and Organized

It is important to stay informed and organized throughout the process. Keep a record of all the information you gather, including eligibility details, benefits coverage, and reimbursement procedures. Stay in contact with the insurance company and the patient to ensure that you have the most up-to-date information.

Step 9: Consider Seeking Professional Assistance

Navigating the world of insurance can be challenging, and mental health billing is no exception. Consider seeking assistance from a professional billing service or a trained staff member who understands the intricacies of mental health billing and insurance industry regulations. They can help streamline the process, improve collection rates, and reduce the administrative burden on mental health professionals.

What to do if your claim is denied

If your insurance claim is denied, there are several steps you can take to appeal the decision. Here's what to do:

• Review your Explanation of Benefits (EOB): By law, most health insurance plans must provide a written EOB after a claim is filed, detailing how much the insurance company paid and any remaining amount you owe. The EOB will also explain why your claim was denied. Common reasons for denial include seeking treatment from an out-of-network provider, lack of precertification or preauthorization for a procedure, not meeting your deductible, or receiving a service that is not covered by your insurance.
• Review your Summary of Benefits and Coverage (SBC): Your SBC outlines what benefits are covered and not covered, as well as any deductibles, copays, or coinsurance you are responsible for. If you're still unsure why your claim was denied, contact your health insurance company for clarification.
• Check the No Surprises Act: If you get health insurance through your job, Healthcare.gov, your state's marketplace, or directly from an insurance company, the No Surprises Act may protect you from unexpected bills for healthcare received on or after January 1, 2022. This act covers most emergency services and prevents providers from charging out-of-network cost-sharing or billing extra for services from non-network providers at an in-network facility.
• Contact your health insurance company: Claims are often denied due to billing errors or missing information. Call your insurance company to discuss the issue and determine if this is the case. Have your health insurance card, details of the visit (date, provider, reason, etc.), and the EOB ready when you call.
• Contact your healthcare provider: If your insurance company determines that your claim was denied due to an error, they may contact your healthcare provider to resolve the issue. You may need to act as the go-between, calling both your provider and insurer to facilitate communication and speed up the process.
• Enlist your employer's HR department: If you receive health insurance through your job, your employer pays the bulk of your premiums and has a vested interest in ensuring you get the coverage they're paying for. If your attempts to resolve the issue with the insurance company are unsuccessful, your HR department may be willing to step in and help.
• File an internal appeal with the insurance company: Under the Affordable Care Act (ACA), non-grandfathered group health insurance plans and carriers selling insurance to group and individual markets must allow consumers to file appeals when claims are denied. Contact your insurance company to learn the process for filing an internal appeal and whether there is a deadline to do so. Typically, you will need to provide the EOB denying the claim, a letter from your doctor explaining why the treatment was medically necessary, and any supporting documents such as test results or medical records.
• File an external appeal: If the insurance company denies your internal appeal, you have the right to file an external appeal with an independent review organization, which will review your claim and make a final decision that the insurance company must abide by. You can file an external appeal if the denial involves a medical decision where your healthcare provider disagrees with the insurance company, or if the denial involves a treatment that the insurer considers experimental or investigational. Your EOB or most recent denial letter will provide information on how to contact the independent review organization.

Frequently asked questions