It's no secret: understanding health insurance is really difficult.
We've put together this guide to try to make dealing with insurance as easy as possible.
We make every effort to make the insurance claims process as straightforward as possible for you. We will contact your insurance company in advance of your first session to estimate your costs, and submit and process in network claims ourselves. However, any benefit information we provide to you is an estimate of the expected cost, not a guarantee. We estimate as precisely as we can, but occasionally, we encounter situations where the insurance company does not pay what we expect. In those situations, it falls to you as the client to pay any amount still due.
We encourage you to be familiar with your insurance company and benefits. Before your sessions, you can estimate your costs by finding out your benefits. After your sessions, you will receive an Explanation of Benefits (EOB) from your insurance company, explaining what costs they paid, and what costs you are responsible for paying.
There are two ways that health insurance saves you money:
When we are "in network" with an insurance company, that means we have agreed to accept a reduced rate for our services. Rather than getting paid our standard $150 fee, we agree to accept a lower fee, ranging from $60 to $149. This is called the "contracted rate" or "negotiated rate."
The insurance company then takes the negotiated rate and splits the cost with you. When you use your health insurance, you pay part of the negotiated rate for the service, and the insurance company pays the rest.
The negotiated rate applies right away, but sometimes you have to pay a deductible before cost sharing begins:
A deductible is a threshold that you pay before insurance starts sharing costs. For example, if the negotiated rate is $100, and you have a $1,000 deductible, then you would pay for the first 10 sessions at the full $100 rate. After you had paid a total of $1,000, then cost sharing would begin, so from then on you would pay only part of the $100 fee, and insurance would pay the rest.
Cost sharing take can take two different forms:
A copay is a flat amount of the negotiated rate that you pay. For example, if the negotiated rate is $100, and you have a $10 copay, then for one session, you would pay us $10, and the insurance company would pay the remaining $90.
A coinsurance is a percentage of the negotiated rate that you pay. For example, if the negotiated rate is $100, and you have a 15% copay, then for one session, you would pay us $15, and the insurance company would pay the remaining $85. Typically, plans with a coinsurance have a deductible you must reach first.
Common insurance pitfalls:
Benefits reset every year
Every insurance plan resets once a year. Often this is on January 1st, but some plans reset at other times of year. When the plan resets, that means the copay or coinsurance may change from what they were the previous year, and that any deductibles will reset to the full amount. Make sure you know when your insurance plan resets, because the amount you pay us may significantly change at that time.
For instance, imagine the negotiated rate was $100, and you had reached your deductible for the year. You could be paying just a 10% coinsurance per session, equaling only $10. On January 1st, the deductible would reset, so instead of paying $10, you would suddenly be responsible for paying the whole negotiated rate of $100 for each session until you reached the deductible again. On December 31st, a session could cost you $10, and on January 1st the same session could cost $100. Get familiar with your benefits so that you're not caught by surprise when your cost changes!
Different benefits for in person and telehealth sessions
Some insurance plans have started offering different benefits depending on whether the session happened in person at the office or via telehealth. Some plans charge you more for in person sessions, others charge more for telehealth sessions. When checking your benefits, be sure to ask whether the benefits are the same or different depending on whether the session was in person or remote.
Tiered insurance plans
Some insurance plans have different benefit tiers for different providers. An insurance plan may have up to four different tiers, each with different benefits, and split their in network providers among these tiers. We could be in any tier, depending on the specific plan. Be sure to find out if your plan has tiers, and if so, which tier we fall in, and what the benefits are for that specific tier.
Mental health benefits carved out
Some health insurance plans subcontract the mental health portion of benefits to other companies. For example, while your general medical benefits may be offered through Aetna, it may be that mental health is "carved out" to another company. If we aren't in network with that other company, then we are not considered in network for your plan, and can't accept that insurance plan.
Finding out what the benefits are for your insurance plan:
Every insurance company provides "plan documents," which are the documents where all the plan details, including benefits, are written out. Ideally, outpatient mental health benefits are well-labeled and easy to find within the plan documents.
Often, the easiest and most accurate way to learn your benefits is simply to call the insurance company and ask. There should be a customer service phone number on your insurance member ID card.
Questions to ask about your benefits:
Does my plan have outpatient mental health benefits?
Is there a deductible that applies to this benefit?
What is the deductible?
How much of the deductible has been met so far this year?
Is there a coinsurance?
Is there a copay?
Is prior authorization required?
When do benefits start, renew, and end?
Are benefits the same for in person and telehealth sessions?
Walnut Psychotherapy Center
Danna Bodenheimer, LCSW
Group NPI: 1659749497
Address: 1700 Sansom St Fl 11
Philadelphia PA, 19103
Outpatient Mental Health Services
Office setting, or telehealth
Individual sessions: 90837 or 90834
Couples sessions: 90847