A little reassurance first: My patients have said that the process of getting reimbursed by their insurance is much easier than it initially sounds — and I’m glad to help make it as smooth as possible for you.
1. First, get informed!
Here’s an important thing everyone with insurance needs to understand: Insurance companies use some “creative” ways to determine the basis of what they’ll cover. It’s not just that your plan says it’ll cover, say, 80% of the cost of psychotherapy — it’s 80% of what they say psychotherapy costs. That’s an important number.
(They get crafty about how they come up with that number, and even what they call it, by the way. Sometimes they use something called Usual, Customary, and Reasonable (“UCR”). Or reasonable market value… a number they can basically just make up. Or they’ll use a percentage of Medicare rates as the basis for how much they’ll pay — even if you aren’t eligible for Medicare, which is specially negotiated insurance for people 65 or older, younger people with disabilities, and people with End Stage Renal Disease.)
Keep in mind that they use that number — what they say psychotherapy costs — to calculate your reimbursement. For example, if your insurance plan says it covers 80% of psychotherapy fees, what that really means is they’ll pay 80% of what they say the typical fee for psychotherapy is.
The catch is that there are very few regulations for how they determine that number. And, they usually won’t tell you (their customer!) what that number even is — calling it “proprietary information.”
Good news, though! Thanks to numerous class action lawsuits, and legislative work on healthcare laws, there’s a consumer rights website where you can see what an objective source says the typical fees are in your area.
The site is Fair Health Consumer, and here’s how to use it to look up the Typical Provider Charge (Fair Health’s term for UCR) for psychotherapy in your area:
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- Enter the Zipcode of your therapist.
- Enter the procedure code; 90834 is the procedure code for individual outpatient psychotherapy, 45 minutes, or you can ask your therapist what code they’ll use.
- Click “See Out-of-Network Reimbursement”.
- Scroll down to “Cost Breakdown” (ignore the first few rows you see on the page — those includes other charges like hospitalization).
There you have it! Now you know the real typical cost for psychotherapy in your area, and you’re armed and ready to call your insurer.
2. Call your insurance company
When you call, they’ll first let you know what your insurance plan covers in general terms — for example, 80% of “the UCR.”
(So, for example, if your insurer considers $200 to be the UCR for psychotherapy, and you have 80% coverage, they’ll cover $160.)
Now you’ll want to ask about what to expect for reimbursement for psychotherapy. For example, if you were to call about reimbursement for psychotherapy with me, you’d tell your insurer this information:
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- You’ll be submitting claims for “Individual Psychotherapy, Outpatient, 45 minutes,” also referred to as CPT code 90834.
- My current fee for CPT code 90834 is $290.
- My Zip code is 20036 (reimbursement varies based on location).
- I’m a licensed psychologist, and I’m a non-participating provider (meaning I’ve chosen not to have a “contract” with any insurance companies).
Then ask them if your therapist’s fee is within the range of what they use to determine reimbursement. If they say anything, they’ll typically only say either “yes” or “no”.
If they say no, or that they can’t tell you that, you can tell them you’ve used the Fair Health Consumer site to look up the Typical Provider Charge for psychotherapy in your area, and that the amount is $_____ (whatever you’ve found using Fair Health). Then ask them if that figure is what they use to determine reimbursement — and if not, why not!
3. Ask your psychotherapist for help and guidance
Clearly, insurance companies prefer to skew the “game” to their advantage, not to patients, and all therapists are aware of this. Therapists should also be able to help if insurance companies aren’t playing fair, and guide you about the ins and outs of getting the reimbursement you’re due.
Like many healthcare providers, my patients pay me my fee directly, and then file for reimbursement. If my patients run into any snags, I’m there to help and guide them, whether it’s with CareFirst, United HealthCare, Aetna, Cigna, or any other insurance carrier.
Having had more than two decades of experience with helping patients get the reimbursement they’re due, I’m skilled at it, know the ins and outs, and am glad to help my patients get the full amount of reimbursement they’re actually due.