Navigating the Insurance Landscape
Updated: May 5
Maximize Reimbursement for Behavioral Health Services
Navigating the insurance landscape when trying to get therapy services covered can be a minefield. It is important for clients to understand why this happens. While the stigma surrounding mental health has improved in recent years, the change has yet to reach far enough to positively impact full parity with regard to coverage of mental health services vs. physical/medical services, negatively impacting the client.
Insurance carriers will only agree to low rates with clinicians who try to join their network or “get paneled.” Contract rates are often less than half of what a clinician can reasonably charge on the open market. This leads to a few negative outcomes:
1. Fewer clinicians take any insurance. In order to run a business effectively and help the most people with the highest treatment success rate, many clinicians view accepting contracted rates through insurance as an unmovable barrier.
2. The clinicians who take insurance are unavailable. Due to the shortage of paneled clinicians, those who do take insurance often have very long waitlists. Additionally, as a result of the low contracted rates, in-network clinicians need to take more clients to run the business successfully. The number of clients seen per week often gets too high, increasing clinician burn out and lowering success rates with clients.
3. Ghost Networks. There has been more attention paid to this in the media as of late (https://www.bostonglobe.com/business/2018/12/11/aetna-settles-with-state-over-ghost- networks/AmnsHaunRIhj50uGqYwaeN/story.html), and hopefully even more light is shed on this as we move forward. Ghost networks are essentially an insurance company’s way of making it look like they have plenty of available clinicians on their website or patient portal, when in reality few of the listed names are legitimate options. Some names listed left the panel long ago, others are full and have long wait lists. Some clinicians never actually joined the panel and yet their name was listed anyway, and others have even passed away! Ultimately, what you see is not what you get, and this can lead to an incredibly stressful search process, as the client begins to call these options in hopes of connecting with an available clinician, only to run into multiple dead ends. When looking for a therapist, stress and wasted time do not help, that is for certain.
If a client decides they want to work with a clinician who does not contract with insurance companies, often referred to as an “out of network clinician,” it is important to know how to maximize the chances that this will be successful and covered/reimbursed by insurance as much as possible. Here are some tips:
1. Make sure there is a good connection with the therapist first. Often, this can be achieved through a free consultation. Many skilled clinicians offer a free consultation as a way for clients to meet for 20-30 minutes prior to officially deciding on fit.
2. Make sure they specialize in what you are looking for. The clinician should be able to speak to their expertise and level of comfort in working with your main goal(s). If a clinician can’t paint a clear picture of how they plan to get you the desired results, it might be worth looking at other options.
3. Call the insurance company to get the exact details of your plan in terms of what is covered for “outpatient behavioral health services.” Ideally, you want to know:
Is there a deductible and if so, how much? The deductible is the up front amount a client has to pay prior to the insurance covering ANY services. Often, this needs to be paid out of pocket by the client regardless of whether they work with an in-network clinician or a clinician who is out of network. If the deductible is $1,000 that means the client has to pay out of pocket for all sessions up to that floor of $1,000. After the floor is reached, the insurance will cover a percentage of services thereafter.
What percentage will the insurance either cover or reimburse? Usually, the number is around 80%, which means the large majority of costs will be covered/reimbursed by insurance. You want to make sure you get the exact %.
What is the floor that needs to be reached for insurance to cover/reimburse 100%? Sometimes, plans will have a number that when reached, triggers the insurance to cover ALL costs of treatment for the remainder of that year. You want to ask if your plan has this and if so, what is the amount.
Is there a max allowable? Some insurance plans will cap the total amount covered at a certain ceiling, a question worth asking just in case this exists.
Will the insurance company cover/reimburse out of network behavioral health services? If yes, you want to get the exact % that they cover, as well as the exact process needed to submit paid invoices to be reimbursed. Often, the client has to pay the clinician, and then submit the paid invoices to the insurance company to be reimbursed to the client. Insurance companies will often leave out details intentionally, that way when a clinician or client submits claims or paid invoices seeking reimbursement, the insurance company can deny payment. You have to get the exact process needed to be reimbursed. This mainly includes what the clinician is required to list on the paid invoices to ensure approval of reimbursement (often client name, date of birth, diagnosis, session date, CPT code, clinician NPI number and/or tax ID number, clinician address and phone number, etc.). Some insurance companies also have a separate one page form that needs to be submitted either by the client, clinician, or both, in the beginning to allow for future paid invoices to be submitted and approved for reimbursement of funds to the client. Other insurance companies do not have any forms, they only ask for paid invoices with specific information listed. Make sure you know the exact details here, and whenever possible, get the insurance company to put it in WRITING, that way you can refer back to this when (not if) they try to deny reimbursement.
4. If the insurance company says “sorry, we will not cover out of network services,” most clients give up. You should keep going. Many insurance companies set up their system to bank on clients and clinicians giving up easily, whether that is for denied claims or for getting out of network services approved. Ask to speak to the supervisor, keep asking until someone says yes.
If you can prove to the insurance company with call logs and/or email exchanges that you reached out to 10 or more in-network clinicians and no one got back to you or the clinicians that responded all have a wait list, the insurance company is legally bound to approve what is called a “single case agreement.” Remember that term, because you want to keep asking how to get this approved. Here is a link to an article that reviews the legally binding aspect: https://www.masspsych.org/page/58
A single case agreement is where the insurance company will approve, for a certain time period or number of sessions, a client to work with an out of network clinician. In a single case agreement, the insurance company agrees to pay what their typical contracted rate is, and the client is responsible for the rest. In these scenarios, the client will pay the clinician, and then submit the paid invoices to be reimbursed by the insurance at the contracted rate, which is usually 50-60% of the full cost.
5. Other tips: In addition to proving to insurance that in-network options do not exist, you can also use specialty/flexibility as reasons to convince them to approve a single case agreement. If the clinician specializes in your main treatment goal or your client demographic, that is a reason to demand the opportunity to work with them, regardless of whether they are in-network. Flexibility in scheduling matters as well. If the clinician has weeknight and/or weekend hours, that might a reason to demand approval to work with them. Some clients have very busy work schedules and no vacation/sick time flexibility, and may require a clinician who holds open weekend or weeknight hours.
Keep advocating for yourself or loved one who needs services. If you keep proving need and asking for approval to work with the RIGHT clinician, your odds of getting services covered/reimbursed go up and up. Insurance companies have a playbook they follow, and it’s designed to not lose money. Remember that, and remind yourself that in order to bypass their playbook, you have to keep at it, minimize discouragement if possible, and never give up. Hopefully, in a day not far away, insurance companies will contract clinicians at fair rates, allowing every clinician to accept insurance.