Obtaining fair and accurate insurance reimbursement

Getting the Information You Need To Receive Fair and Accurate Insurance Reimbursement for Psychotherapy

While I do accept some insurances, I am not an in network provider for some of the insurances. Many insurance plans do include “ an out of network benefit”. You may or may not be aware of this benefit. There is typically a deductible to meet and thereafter the insurance company will reimburse you for a percentage of the fee you pay for psychotherapy.

I am including this guide to help you get the information you need from your insurance company to get the full benefit of your policy.  Make sure your insurance company is handling the reimbursement fairly and accurately, and that their formula for calculating your reimbursement is based on reality.

First, call your insurer. They’ll let you know what your policy covers in general terms — for example, 80% of the “usual, customary, and reasonable” fee, or UCR.  This is the amount they claim psychotherapists in your area charge for therapy.

Unfortunately, insurance companies usually won’t tell you what they consider to be usual, customary, and reasonable, nor how they calculate it. Often, they’ll say that this is “proprietary information.” It’s also often much lower than what the prevailing rate actually is.

If this happens, tell them (a) the fee that the psychotherapist charges for therapy, and (b) the Zip code where the therapist is located. For my services, here is the information you’ll need:

The typical services I offer are :

  • “Individual Psychotherapy, 45 minutes”. The code for this is 90834

My fee for this is $130.

  • “Individual Psychotherapy, Outpatient, 53 minutes,” also referred to as CPT code 90837

My current fee for that service is $150.

  • My Zip code: 01950 (reimbursement varies based on location)

Then ask if my fee is above what they’ve set as the UCR. They might only say “yes” or “no” (or refuse to answer) — so you won’t know if my fee is only slightly above, or far above what they claim is reasonable and customary. For the majority of my patients, my fee is either within or just slightly above the UCR for their insurance policies and benefits coverage.

Unlike most aspects of health insurance, there are very few regulations for insurance companies for how they determine what is reasonable or customary. In fact, only a few states even define what “usual, reasonable, and customary” means, and even fewer have regulations on the formula insurance companies use to determining that figure.

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 your particular geographic area (therapy costs more in Boston than in, say, Iowa). The site is FAIR Health Consumer (http://fairhealthconsumer.org/medicalcostlookup.php). FAIR Health was established as part of the collective settlement the New York State Attorney General’s office reached with insurers (FAIR Health: Who We Are).

On the FAIR Health lookup page, type “01950″ for the zip code, and “90837″ for the CPT code (the code for individual outpatient psychotherapy, 53 minutes). Again, for many of my patients, my fee is either within or only slightly above the UCR for their insurance benefits coverage.

If your insurance company’s figure for the UCR is lower than what the FAIR Health Consumer site shows, you’ve got firm grounds to have them adjust it. If they protest, simply ask them for the names of ten psychotherapists in the 01950 Zip code who charge the UCR they’ve set, and who are accepting new patients. They probably can’t, exposing their inaccurate, incorrect, and possibly illegal UCR determination.

Like many healthcare providers, my patients pay me the full 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.

With more than thirty years of experience with helping people get the reimbursement they’re due, I’m skilled at helping my patients work with their insurers to get the full amount of reimbursement they are actually due.

I wish you well with your work in psychotherapy.


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