In an earlier article, (Does My Insurance Cover Therapy?) I explained many common insurance terms and ways that insurance does or does not cover therapy. In this article the focus is more on how you can utilize your insurance for therapy. I am going to talk about it in three sections, in-network providers, out of network providers, and single case agreements.
In Network Providers
If you have an HMO, EPO you are almost exclusively limited to in network providers, and if you have a PPO plan, you still have in network benefits. There are some exceptions to this but the main one will be covered in the section on single case agreements.
First off, you need to find an in-network provider. This must be a licensed therapist, social worker, psychologist, or psychiatrist that is on a panel with your insurance company. This can be very difficult if you go about it the wrong way, because on many sites like healthgrades.com or psychologytoday.com, providers will list insurances that they take both in and out of network and so it will not help you. The easiest way to find an in-network provider is to go on your insurance company’s website and look for approved providers. If you are not technologically savvy you can also call your insurance company and ask for a list of providers.
After you find an in-network provider you need to schedule an appointment and give the provider a copy of your insurance to submit for billing. When you arrive for each of your sessions you will be asked to pay your co-pay, which is the amount of the cost you are required to pay by your insurance.
At this point your insurance will usually give a number of days/sessions approved to the provider. You now have that number of sessions for your therapy before your provider must request additional days from your insurance, terminate you from treatment, or you must pay the whole cost yourself. Even if you get denied approval for a claim, you can often appeal any such decision, though this can take a lot of work.
Here at Coherence Associates, we are not on panels with any insurance companies. We are considered a fee for service based company, where clients pay at the time of the service.
Out of Network Providers
If you have a PPO (Preferred Provider Option) insurance plan, you have more options for therapy than with an EPO or HMO. The in-network providers are the same as above, however you can also see out of network providers. This process is much simpler. The co-payment and reimbursement rate for out of network providers may be different than if you select to use an in-network provider.
For out of network providers, they generally work on a fee for service basis, which means you pay them, and your insurance reimburses you. The process goes as follows:
Find a therapist you want to see
Schedule an appointment
Ask for a receipt so you can send a super-bill (submit your claim) to your insurance
Collect your reimbursement from therapy sessions.
Depending on the price of your therapist, you may get all some or none back from your insurance. The these can vary session to session, but the averages I have seen range from $30-$90 reimbursement per session, though to this day I have no idea how an insurance company decides how much to reimburse, and I have tried to learn.
Like many other practices, we at Coherence Associates are a fee for service practice, this means we take payment from our clients at the time of service. We do not take in-network clients, but we can give you a superbill that you can submit to your insurance for reimbursement. This only applies to PPO plans with out of network benefits.
Single case agreements are where a therapist, or doctor, who is not on panel with an insurance company, makes an agreement with an insurance company to provide services for a specific rate, for a single client. These are not common, are difficult to manage, and tend to be used when no appropriate in-network providers of similar services are located within reasonable distance of the client.
Remember, if you are struggling, and are having problems understanding or using your insurance, feel free to call us at (760) 942-8663 for a free screening, and if we cannot help you use your insurance, we can help you find someone who can.
By Jeremy Larsen
Business Development and Operations Manager
Coherence Associates Inc.