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.
Knowledge is power, so it’s good to know what to expect as reimbursement for psychotherapy — and how to make sure your insurance company is handling the reimbursement fairly and accurately according to your insurance coverage. That’s why I’ve written this guide. I hope you find it helpful.
1. Call your insurance company to find out your coverage
You’ll need to call your insurer, specifically for “mental health” services (often handled by a different department than medical claims, or sometimes by a different company).
When you call your insurer, they’ll let you know what your policy covers in general terms — for example, 80% of the “customary and reasonable” fee (this might also be called “usual, customary, and reasonable”, or UCR, the term I’ll use here).
So, for example, if your insurer only considers $90 to be the UCR for individual psychotherapy, they’ll pay 80% of that, or $72. (After you’ve met your deductible, that is.)
2. Get your insurer to tell you how they calculate your reimbursement
Unfortunately, insurance companies usually won’t divulge what they consider to be usual, customary, and reasonable. Often, they’ll say that it is “proprietary information.”
What you can do to work around this is to tell them the fee that the provider charges for a particular service, in a particular geographic area or zip code — and to be educated about the prevailing fees in your area.
So if you call about what to expect for reimbursement for my services, that would be:
• 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 $220.
• My Zip code is 20036 (reimbursement varies based on location).
• I’m a licensed psychologist, and I am a non-participating provider (meaning that I have chosen not to have a “contract” with any insurance companies).
Then ask them if my fee is above their UCR — what they’re willing to pay for that service. When you ask them, if they say anything, they’ll typically only say “yes” or “no” — so you won’t know if the fee is only $5 more, or $100 more than what they claim is reasonable and customary.
3. Know the rules of the “game” and be an informed consumer
Unlike most aspects of health insurance, there are very few regulations for insurance companies when determining what they consider reasonable or customary. In fact, only a few states even define what constitutes the terms “reasonable, usual and customary” and even fewer have regulations on the methodology used in determining these charges.
There’ve been some changes about this (after many class action lawsuits, and work on healthcare laws). You can go to a consumer rights site and see what an objective source says the customary rates are in a particular geographic area (therapy costs more in DC than in, say, Iowa).
The site is Fair Health Consumer. Type in “20036” for the zip code, and “90834” for the CPT code (that’s the code for individual outpatient psychotherapy, 45 minutes).
The last time I checked at the website above, my fee was at about the 90th percentile for psychotherapists in DC. For many of my patients, that’s either within or only slightly above the UCR for their insurance policies and benefits coverage. Most of the time, insurance companies use the 80th percentile as the basis for the UCR.
4. Ask your psychotherapist for help and guidance
All psychotherapists are aware that insurance companies prefer to skew the “game” to their advantage, not to patients. 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. I provide a statement at the end of each month that includes all of the information you’ll need to file a claim, and you send it to your insurer along with one of their claim forms. If my patients run into any snags, I’m there to help, 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 and glad to help my patients work with their insurers toward getting the full amount of reimbursement they are actually due.
I wish you well with your work in psychotherapy.