getting insurance to finance specialized therapy
No matter how you feel about the whole health insurance debate in the United States, I think most of us can agree that dealing with insurance companies can be confusing and frustrating. It can almost seem like the insurance companies have their own special language and code words. If you have a child in need of specialized therapy, or you are in need of therapy yourself, going through your insurance can seem really daunting and to add to the difficulty, many specialists no longer deal with insurance. My hope is that this post will help you navigate the way US insurance companies work so that you can get services paid for (even if they are out-of-network).
Do not let your insurance’s first response, where they say they are not funding an out of network provider, or they say they will but will only pay 20%, throw you off. You still have options, they just aren’t going to tell you what they are. Let’s start with a quick primer on insurance “lingo” you need to know:
in-network providers- are providers covered by your insurance company. If you are going to an in-network provider your insurance company has an agreement with your provider so that they are likely to pay most of the bill except for your regular co-pay.
out-of-network providers- are providers your insurance company does not have an agreement with. If you are calling your insurance company and they say the provider you are calling about is out-of-network, you will want to ask if you have out-of-network benefits on your plan. If they say no- do not panic- you have options!
usual customary rate (UCR)- is the rate your insurance customarily agrees to pay for a given service. When your insurance says they will pay 70% of the UCR that means they will pay 70% of what they normally agree to for that service- which is often different from what the specialist charges. If your insurance says they cover a percentage of the UCR, ask them what the UCR is for the service you are getting. If they say $80 and they cover 70% of the UCR, that means they will reimburse you or the therapist $56 and you would be responsible for the remainder of the UCR if you are seeing an in-network provider, or the remainder of the provider’s fee for out of network providers.
Now that you know these terms. give your insurance a call and see what they have to say about the provider you want to see. Remember to also ask if you have a deductible and how much of your deductible has been covered. Other insurances have a rate that changes, for example, they pay 20% for sessions 1-5, 40% for session 6-30 and 70% for sessions 31 and above. Don’t worry, I’ll summarize at the end so you can get all the questions together.
So, what do you do if your insurance company tells you your chosen specialist is not covered?
Gather the information that makes your provider special. Do they have special skills and training to help your child that other providers do not have? My clients that call would tell their insurance I have specialized training in trauma, attachment and adoption- if they are bringing their children for one or all of those reasons- pick only the issues that pertain to you and your child. Ask your insurance if they have anyone in-network that provides that same level of expertise. Your insurance is required to find someone with comparable skills within a reasonable distance of your home who has the specialized skills you require. If they do not, they are required to offer to pay their UCR to your specialist. If you have a willing specialist, with just a short conversation with your insurance, they can negotiate a rate for services. I have done this several times now.
To summarize, the questions for your insurance are:
1. Is (name of the provider) in-network for my plan?
2. Do I need authorization?- asking the question starts the process if you need it.
3. If my provider is out-of-network, do you have an in-network provider with the same skills and availability within reasonable distance from my house?
4. If you do not have anyone in-network, could you offer the provider a single case agreement?
5. What is my deductible?
6. What is the reimbursement for this service?
7. If they mention UCR, what is the UCR?
Remember, if they say they have an in-network provider with the same skills as your specialist, make sure to follow up and call that specialist to make sure they are taking clients because if they are not, you can call the insurance back to report and they need to find someone else or offer a single case agreement.
In case you understand better with a flow chart, I have included one of those below as well. If you have further questions or would like clarification, please ask in a comment. This stuff is confusing and someone else probably has the same question!
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Kate Oliver, LCSW-C (Licensed Clinical Social Worker) has been a clinician working with traumatized and attachment-disturbed children for the last thirteen years. She is co-owner of A Healing Place, a successful private practice in Columbia, Maryland, since 2007.
Kate earned her BA from Goucher College in 1997 and her Master’s in Social Work from the University of Maryland in Baltimore in 2000. Kate first worked with the Sexual Trauma, Treatment, Advocacy and Recovery Center (STTAR Center) working with abused and neglected children in Columbia, Maryland. While working for the STTAR Center, Kate found that while some children responded to traditional child therapy practices, there were a significant number of children who showed little or no improvement in their overall emotional well-being. Kate sought out specialized training to learn more about attachment, the bond between parents and children, and found that by using attachment-based strategies built upon research by John Bowlby, and Mary Ainsworth, and models that foster parent/child attachment, even the most challenging children and their parents, saw major, life-changing shifts, not only for the children she was working with, but the parents as well.
After the STTAR Center, Kate accepted a position with Tamar’s Children, a program that took pregnant, incarcerated women from prison to a treatment facility that worked on teaching the women to bond with and attach to their babies, while also helping the women to heal their own broken attachments, and history of trauma and addiction. Kate was quickly promoted to Clinical Director of Tamar’s Children. The program was internationally recognized for having a successful, evidence-based practice using an attachment-based model. From working with some of the most severely disenfranchised parents, Kate received important information about how to help all parents maintain a happy, healthy relationship with their children with little or no additional financial investment for the parents.
In 2007, Kate co-founded A Healing Place, a mental health private group practice in Columbia, Maryland, where she focuses on working with families with children who have a history of trauma and/or attachment disturbances. A board certified supervisor, Kate has been an invited presenter to teach continuing education courses for other social workers and psychologists. In her courses, Kate teaches attachment-building techniques and presents about her sub-specialty, working with families headed by gay and lesbian parents.
Kate is a former board member for the organization COLAGE, a non-profit group that works toward community building for people with gay, lesbian, bisexual and/or transgender parents. She is currently a member of Attachment Disorders Maryland, a group that works to educate parents and professionals about working with children with attachment related issues.
Kate lives in Columbia, Maryland is the mother of two amazing daughters, the partner to a fantastic husband, and the daughter of one mother and two gay dads. She loves to read any book that crosses her path, write (of course), and she recently started dancing again, a passion she has had since her youth.
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