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Health Insurance and Mental Health Services

Highlights:

  • We're in network with most BCBS plans. Some of our therapists are also in network with other insurance plans.

  • You are responsible for knowing your insurance benefits, but we will try to help.

  • You should call your insurance company and ask if your provider is in network, whether the service is covered, and how much you have to pay out of pocket.

  • This still may not get you a completely accurate picture up front, but it may get you close to predicting your likely out-of-pocket costs.

  • If your insurance company does not pay us, you are responsible for payment. 

mental health counselor waiting room

Health insurance is confusing and sometimes frustrating. While our self-pay rates are very competitive in Cary, Raleigh, Apex, and the surrounding areas, individuals with health insurance are finding that their out-of-pocket costs are rising. 

 

First, a disclaimer. We are not health insurance professionals, so we cannot give you official information or advice about your health insurance benefits. We offer the following information based on our experience with health insurance companies. You should verify directly with your insurance whether the services you seek at Etheridge Psychology will be covered.

Your coverage is a contract between you and your health insurance company. We have no control over which services your insurance company will cover or how much you must pay out of pocket for services. 

Are services at Etheridge Psychology covered by my health insurance?

 

  • If your provider is in your network and your visit meets medical necessity guidelines, services should be covered. You may still owe a copayment, coinsurance, or deductible even if you're covered.

  • We attempt to verify benefits just prior to your appointment rather than when you make your appointment because insurance coverage can change. If you want to know your benefits sooner, we encourage you to call them.

  • We cannot guarantee that the quote of benefits was correct or that your insurance will pay what they have said that they will pay. Insurance companies tell us every time we call them that a quote of benefits is not a guarantee of payment and that payment decisions are made when the claim is processed (i.e., sometimes weeks or even months AFTER your appointment).

  • If you're seeking psychological testing, we will provide you with an estimate of what your costs could be if your insurance company does not process their claims as anticipated. If you do not receive one at your first appointment, please ask. 

 

Even if your insurance tells us that you will only have to pay a $25 co-payment, they can still deny the claim or decide to apply the entire bill to your deductible when they process the claim, resulting in you having to pay much more. Unfortunately, we have no control over what portion of your bill your insurance company will pay and cannot predict whether they will pay the claim. 

Is my clinician in-network with my health insurance?

 

  • All of our providers are in-network with most, but not all, BCBS plans. 

  • Some of our therapists and psychologists are in network with Cigna, Aetna, Tricare, and/or Medicare as well. 

  • We cannot guarantee that the clinician you see at Etheridge Psychology is considered to be an in-network provider for your specific plan.

  • Calling your insurance company is the best way for you to find out. 

 

How do I find out if services will be covered?

 

While we do try to verify benefits as a courtesy, healthcare providers are not required to verify patient benefits and eligibility with insurance companies. We recommend that you contact your health insurance company prior to your appointment with us or any other healthcare provider and ask the following questions:

 

  • Is (name of clinician) considered to be in-network under my mental health benefits?

  • I am seeing (name of clinician) for (therapy, psychological testing, etc.); is this a covered benefit?

  • Do I have to pay a copayment, coinsurance, or deductible for this service? How much?

  • Is pre-authorization required for this service? If so, how do I get preauthorized?

 

Information you receive from your insurance company is still not a guarantee that they will pay; you still have to meet medical necessity guidelines.

 

What are some reasons my claims might get rejected?

  • If your clinician determines that you have no mental health diagnosis, the insurance company may not pay. 

  • Some diagnoses are excluded, such as learning disorders. 

  • We cannot know what your diagnosis will be until we have evaluated you. 

  • If your visit is relating to a legal issue, Worker's Compensation, a disability application, a fitness for duty examination, educational purposes, or any other reason that does not meet medical necessity guidelines, our contract does not allow us to submit a claim for you.

Psychological testing can be expensive, so please consider whether you can pay the balance if your insurance company decides not to cover it. 

 

Why am I getting a bill months after my appointment?

 

We submit insurance claims quickly, but your insurance company may take a month or more to process your claim. If your claim is denied, we contact the insurance company on your behalf to try to resolve the claim. If the insurance company asks for more information or sends the claim back for reprocessing, it can take another several months! On rare occasions, it has taken more than six months to get a claim finalized, and only then can we send you a bill. 

 

What if I can't pay the amount that the insurance applied to my deductible?

 

  • If your insurance company applies payment for services to your deductible, that means that we did not get paid at all, and you must pay that amount directly to us.

  • Per our contracts with insurance companies, we cannot forgive that balance.

  • After the claim is processed, the insurance company will give us the exact amount that was applied to your deductible. If you owe a balance, we will send you a bill (or a refund if you overpaid).

  • Unpaid bills are subject to collection. We do offer a payment plan if you request one. Ask us for details. Please note that we are always willing to work with you, but you must communicate with us. 

 

What if I have more questions about my mental health benefits?

 

We will help you in any way we can, including filing claims, helping you appeal denied claims, and even contacting your insurance company on your behalf when we can. Please understand, however, that the best source of information about your benefits is your health insurance company. We recommend that you write down the date you called, note the name of the representative with whom you spoke, write down everything the representative told you, and get a reference number. This information may help if the claim is later denied or underpaid. 

 

We hope that this information has been helpful. Please do not hesitate to contact us with any further questions.

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