help4yourfamily

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!

insurance questions flow chart

April 27, 2012 - Posted by help4yourfamily | health insurance, thinking about therapy? | Child, children, counseling, Family, Insurance, mental health, parenting, psychology, Social work