Diagnosis?

Do I qualify?

The first consideration for using insurance in healthcare is whether or not you qualify for a diagnosis.  Insurance companies operate based on helping to pay for the treatment of an illness.  This is known as the medical model.  Most insurance companies honor the illnesses included in the International Classification of Diseases version 10 (better known as the ICD-10).  Insurance companies do not pay simply for you to talk with a counselor.  They only pay if you have been diagnosed with an illness and the doctor or counselor is treating you with an acceptable, approved treatment.

The ICD-10 contains a whole section on mental illness.  Examples include depression, generalized anxiety, stress disorders, and bipolar disorders. There are many mental illness diagnoses.  If you qualify as having the symptoms of one of these, then a Diagnosis can be made for you.

Many people seeking to speak with a counselor do not qualify for a mental illness diagnosis. Ordinary, but stressful life transitions do not qualify.  Neither do marriage issues unless one or both partners are distressed to the point of qualifying for a diagnosis.  So your counselor, during the intake phase of your work, will be assessing whether your cluster of issues and symptoms qualifies for a diagnosis approved by your insurance company.  If your counselor does not think you qualify, then you will not be able to use your insurance for seeing this counselor.

Do I want a Diagnosis?

Even if you qualify for a diagnosis, you might prefer not to have it on your medical record.  If you are diagnosed with a mental illness and you choose to file or have claims filed with your insurance company, then that diagnosis becomes a part of your medical record.  This can be an issue for people seeking security clearances and some life insurance policy applications seek information about mental illness as well as physical issues.  Many people do not want a mental illness diagnosis on their record and thus choose not to have claims filed with their insurance company.

YOUR COUNSELOR: LICENSED OR WORKING TOWARD LICENSURE

Not all counselors can file insurance claims. Counselors who are licensed by the state are qualified to file claims on your behalf.  Counselors who are working towards their license can file claims with limited insurance companies, depending on the insurance company and their agreement with our practice. Counselors have to go through a period of apprenticeship after they earn their Master’s or Doctorate degrees where they work under the supervision of a more experienced professional.  This is usually two to three years but can last longer.   Sometimes a therapist can get a temporary license which allows them to file insurance claims with some companies.  Not all companies honor the temporary license.

IN-NETWORK VS OUT-OF-NETWORK STATUS

In network Billing

Our office works diligently to ensure proper billing when applicable. If you are covered by health insurance with WHC, we will be happy to bill your insurance. Accepting your insurance does not place all financial responsibilities onto this practice, and you will be held accountable for any unpaid balances by your plan. Once you are established, it is your responsibility to update our office with any insurance changes before you are to be seen under a new insurance plan or policy. Failure to do this, or late notice, will result in billing errors and possibly being liable for the full amount of your visit.  As a courtesy, we will inform you, to the best of our knowledge, of an approximate cost per episode of care. Please be aware: the information accessible to us by your insurance company is not always accurate. Your claim will process according to your plan, if your claim processes differently from the benefits we were quoted, your insurance company will side with the plan and will not honor the benefit quote we received. WHC and its employees make no representation, guarantee or warranty, expressed or implied as to covered services or products, network status for your particular plan, or exact costs

In certain circumstances, you may request various sessions to be billed to your insurance if there is a proper billing code available. This is not a guarantee of payment, you are responsible if insurance does not remit payment for the item. Secondary insurance policies do not always pay or guarantee a lesser payment. You will be responsible for paying any amount of primary, secondary or any additional insurance assigns to you. Your responsibility will be based on the most recent plan determination. It is your responsibility as a patient to confirm network status with your individual plan. Insurance eligibility provided to us does not contain this information. You can do this by calling the member services number located on your insurance card.

It is the policy of WHC that payment is due at the time of service unless other financial arrangements are made in advance. We require all patients to pay their deductible, copay, and/or coinsurance payment upon checkout of each visit. If there is an outstanding balance you will be billed. There is a fee for bounced checks or other costs associated with banking errors. Fees are based on bank assignment.

At the time of this notice, our office does not use a third-party billing or collection company. We reserve the right to contract with an outside company in the future. Because we do not use another company and our office is a small staff, there may be a significant delay in mailed statements if you have a balance. There is currently no statute of limitations on the original debt holder sending statements. We do not use the generic generated monthly statements, we have found that these often contain errors. We strive to ensure accuracy and provide each patient with the individual care and time they deserve. If you receive a bill from us, we have taken the time to review your entire account and ensure the amount you owe is correct.  As a rule, due to the sensitive nature of billing and your personal information, we will not inform you of outstanding balances while you are in the office. Instead, we will mail a statement to provide you with an opportunity for a discrete discussion with our staff about your balance. Our office is not in network with any Medicaid plans, regardless of network status. You will be responsible for any charges if billed to a Medicaid policy.

Out of Network

Most WHC therapists are out-of-network providers.  This means that we can file insurance claims for you assuming that there is an applicable diagnosis and that you want us to file.

Most insurance company plans include out-of-network benefits, but not all do.  When you present your insurance card at WHC, we will attempt to verify your benefits.  If we discover that your policy does not have out-of-network benefits, we will inform you as soon as possible.  Sometimes though we will not know this until after we have filed several claims and gotten the Explanation of Benefits (EOBs) back from your insurance company.

Deductible: Assuming that the insurance company plan does have out-of-network benefits, it will almost always have a deductible and something called co-insurance.  The deductible is the number of charges that your insurance company expects you to pay before it begins to help with therapy costs.  So if your deductible is $1,000, then you have to pay for the first $1,000 of charges before your insurance company will start helping with payments.  This deductible amount starts over every new year.  Typically, WHC does not file claims if your deductible is greater than $5,000.  However, upon request, we can go ahead and file those claims even though you are not likely to get help with your counseling costs unless you have significant other out-of-network medical expenses.

Another subtle but important complexity with deductibles is that many insurance companies will not allow the whole counseling fee to be counted towards the deductible.  The amount they allow varies greatly.  But you can see that if they allow only half the fee, then it will take a lot longer to reach that important deductible amount.  These rules are all a part of the contract you or your company has with the insurance company.

Co-Insurance: Once you have met the deductible amount, then you pay Co-Insurance.  For an in-network therapist, you would pay a Co-Pay.  For out-of-network therapists, you pay Co-Insurance.  Co-Insurance is the percentage of the allowed amount that the client pays.  This can be a bit complex and confusing since you the client are responsible for all of the fees that your insurance company does not pay.  So as an example, let’s say the fee is $140 for the session.  You have met your deductible, but your insurance company only allows $100 and your Co-Insurance is 30%.  This means your insurance company will pay 70% of the $100 that is allowed and you get to pay the rest.  In this example, the insurance company pays $70 and you end up paying $70 ($140 fee) even though your Co-Insurance is only 30%.

That previous paragraph might have your head spinning, but that illustrates the complexity of insurance policy reimbursement.  However, having them pay $70 is better than nothing, and this can be a big help especially if you are in therapy for a long time.

 Allowed Fee:  This is one area of insurance where clients are frequently surprised negatively.  When your insurance policy says it will pay 50% of the allowed fee (or usual and customary fee), it does not mean that it will pay 50% of the actual fee.  For instance, if the therapist’s session fee is $140, but the insurance company only allows for a $100 fee, then they will only pay 50% of $100.  So they pay $50 and you get to pay the remainder of $90.  So even though your Co-Insurance is 50%, you end up paying 64%.

Neither your therapist nor WHC has any control over what your insurance company decides is allowable.  You can try to call your insurance company to determine what this is, but for many companies, this number changes frequently.  So, we learn how much your insurance company will help pay when they start paying.

WHC will help you file your claims and get them processed according to the rules of your policy.  It is ultimately your responsibility to know what your policies and rules are.

That previous paragraph might have your head spinning, but that illustrates the complexity of insurance policy reimbursement.  However, having them pay $70 is better than nothing, and this can be a big help especially if you are in therapy for a long time.

Summary Scenario

So as a summary example, you are seeing a therapist who can file insurance, you qualify for a diagnosis, and you want to go ahead with filing the claims.  Your insurance policy has out-of-network benefits with a deductible amount of $1000 and a Co-Insurance percentage of 20%.  (Your insurance company will pay 80% of the amount of the fee they allow after you have met your deductible.)  Now you are all set to go.  The WHC Insurance Team will file these claims for you.  If there is a problem with the insurance process, they will inform you as soon as possible.  You can call your insurance company if needed.  And, in some cases, we can print out a “Superbill” that you can send your insurer if for some reason the claims WHC files are not successful.

We on the WHC Insurance team want to make this process of filing your claims as easy and simple as possible for you and your therapist.  Most of the time, the process goes smoothly and efficiently.  However, feel free to message the Insurance Department through your portal or

call us at 865-297-5077 if you have any questions or information that we may need.  We will partner with you in this, and we wish you the best in your work with your therapist.