Insurance

Insurance Verification

If you wish to submit to insurance, you must first check to see if your policy includes mental health benefits as part of their package.  Second, you then need to check to see if your insurance company lists the therapist you wish to see as one who is on their provider panel.   


Presently, the only insurance companies that PHA as a practice participates with are Blue Shield (Highmark Blue Shield and "usually" BlueCross/Blue Shield, but not always), Capital Blue Cross, and Medicare.

 

If you do have coverage through one of those insurers, it is likely that you will have coverage for services we provide; there are some rare exceptions, however. For example: Some insurers will not reimburse you if you see a provider who is not in their network.  Also, some insurance companies will not reimburse for an hour of psychotherapy (CPT code 90837), but only for abbreviated, shorter sessions (CPT code 90834 or 90832). Some insurers “will” reimburse for 90837, but only if it is pre approved.  


Please understand that our staff cannot stay on top of all the differences in what various insurers cover if we are not under contract with them.  We take no responsibility for misunderstandings you might have with your insurance company! It is strongly recommended to contact your insurer directly to clarify your coverage.  At a minimum, you will want to find out such things as: whether they will reimburse for services to an “out-of-network provider,” what your deductible is, what your copay or coinsurance is, what limits they might have on commonly-used CPT codes (such as 90837), whether they require any type of “precertification” or “preauthorization.” 


If you still have questions about your coverage, our office support staff should be able to help you: let them know you would like assistance by going to THIS LINK.


Medical Assistance

Please be aware that PHA is not a Medicaid provider:  if you have an Access Card for Medical Assistance, be advised that Medicaid will not provide coverage for services rendered by our office!  If you do have Medicaid, even as a secondary insurance, we still might be able to help you, but medical assistance rules are complicated.  Please discuss this with our office support prior to meeting with your therapist.


Sometimes Services Are Not Eligible for Insurance Coverage

Please be aware that to legitimately submit claims to your insurance company, two things need to be true:  First, you must be seeking help for a diagnosis that is considered eligible for coverage (e.g., ADHD, depression, anxiety, etc.); Second, the services you are receiving must be relevant to the treatment of that diagnosis.


Sometimes people seek counseling or therapy for legitimate problems, but it is not related to a medical diagnosis at all (e.g., relationship or couples therapy, or court-ordered evaluations sometimes -- but not always -- fall into this categogry).  Please discuss this with your therapist before beginning treatment.


Do not be deterred if you do not have insurance coverage: the cost of care sometimes needs to be looked at as an investment in a relationship or in your quality of life.  While not having insurance coverage may be inconvenient, insurance coverage need not be a necessity.  In fact, bear in mind that often people elect to not sumit their bills to insurance even when they do have coverage (for more information, see below).


Blue Shield and Blue Cross and Medicare

If your insurance is Blue Shield, Blue Cross or Medicare, and if your therapist is on the provider panel for your insurance company, our office will bill your insurance company directly, and after you have met your deductible, you will be responsible for payment only of your copay (your “copay” is the portion of your bill that your insurance company considers your responsibility and will not pay for).  Until you have met your deductible, you will be responsible for the full amount that your insurance company has contracted with your clinician.  See your insurance policy for details.  Your therapist, or our office support, might be able to help you understand your policy. Please discuss it with them. However, please be mindful that you, not our office support or your therapist, are ultimately responsible for knowing whether your insurance will cover the services you receive.


Other Insurance Companies

If you have an insurance plan other than Blue Shield, Capital Blue Cross or Medicare, it is likely that your insurance plan will still cover the costs of sessions, but you will need to check with your insurance policy to see if they cover mental health services AND whether they cover services rendered by a provider who is "off panel."  Assuming you do have mental health coverage for an off panel provider, typically you will need to pay for services in full at the time they are rendered, and submit your claims to your insurance company yourself.  Unless it is an HMO plan, the chances are that you will be eligible for some insurance coverage for what is called “outpatient mental health services.”  An HMO plan will not cover at all if you go “off panel.”  A POS or PPO plan typically will cover if you go off panel, though they will often give you incentives (such as waiving your deductible) if you go to a clinician that is on your panel. Again, be sure to clarify if you have a mental health benefit.

Sometimes, if your insurance company allows it, your therapist can be reimbursed directly from your insurance carrier, even if he or she is not on their panel.  If such an arrangement is made, please be reminded that this is done strictly as a courtesy for our clients:  it is important to remember that our contract for services, however, is with you, and if your insurance company does not cover or reimburse us for services, you will be ultimately responsible for those expenses (please note that with some managed care plans this is not the case.  If you have such a plan your therapist will be able to let you know).  Payment schedules for other professional services will be agreed to when they are requested.

Managed Care

PHA does not work with any managed care insurance plans.  Managed care is not consistent with our philosophy of care.  Managed care purports to increase the quality of care, while at the same time keeping the costs of care down. The problem is that this is not what happens.  Research shows, as does our experience, that managed care creates cumbersome paperwork and procedures that interfere with the quality of care we are able to provide.  In addition, the amount of information requested from managed care plans is unnecessarily intrusive, and there is concern as well about the privacy of that information once it leaves our office (see below).  Our commitment is to provide the highest quality of care we are able to provide, and to safeguard the confidentiality of the information you share with your therapist in the process.


A Word of Caution Regarding Submitting Claims to Insurance

Many people, even though they have insurance coverage that would allow them to be reimbursed for outpatient mental health services, elect not to submit those claims to their insurance carrier for reimbursement, and to pay instead out of pocket.   The reason is that there can be some “downsides” to submitting claims to insurance.  


Should you decide to submit claims to insurance (many people do), PHA will work with you to expedite the processing of those claims, and all the information your insurance company should need will be provided to them on our billing statement.  Still, we do want you to be aware of some of the issues involved. Please understand that the information provided here is not meant to discourage you from submitting mental health claims to insurance, but is intended to keep you fully informed.


Your insurance company will not provide coverage for a mental health claim unless that claim is submitted along with a diagnosis of a mental health disorder, as well as an eligible procedure code.  You need to be informed, then, that if you do submit claims to insurance there will be a mental health diagnosis code in your (or your child’s) medical record (if you or your child are already receiving medication for anxiety, depression, stress or ADHD, etc., please know that submitting additional claims to insurance won’t make any difference, in that there is already a diagnosis in your record).


We want you to be aware (people do not realize this) that “protected health information” such as service and diagnoses codes becomes a permanent part of your insurance company’s records and is stored permanently in national medical information databases (such as the national Medical Information Bureau’s database, which is the largest repository of medical records in the United States and Canada.  According to the Senate Majority Task Force on the Invasion of Privacy (March 2000), over 700 insurance companies have access to that information.


There is the possibility that this could create problems for you or your child down the road:  The problem is that this information is no longer fully private, and is in fact utilized by other insurance companies as they evaluate “actuarial data” to determine premiums and viability of future applications for insurance coverage. For more information, click HERE.


For managed care plans the concern is greater, because such plans request more specific and detailed information regarding your own personal history, family history, symptoms, behavior, and treatment.  Without that information managed care will not cover the costs of my treatment.  This is one of the reasons PHA does not participate with managed care plans.


Should you choose to submit claims to a managed care plan, it is our policy to routinely work together with you, during your session, to decide collaboratively what information to submit, and how to word your treatment plan and “outpatient treatment request.”  Our office will gladly provide you with a copy of any report we submit, if you request it.  Still, please be advised that Psychological Health Affiliates has no control over what your insurance company does with that information once it is in their hands and we assume no responsibility for how that information is managed after it leaves our office.