Health Insurance and Mental Health Services
Health insurance is confusing and sometimes frustrating. We understand that health insurance premiums and associated out-of-pocket healthcare costs have risen in recent years. 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. Healthcare professionals have no control over which services your insurance company will cover or how much you must pay out of pocket for services. Most insurance companies require you to pay less money out-of-pocket for healthcare services if you see a provider that is considered in-network.
Are services at Etheridge Psychology covered by my health insurance?
You should have mental health benefits as part of your health insurance policy, but only your insurance company can tell you if services with us are covered and how much you will have to pay out of pocket.
We do attempt to verify benefits and eligibility prior to patients' appointments. We are not required to do this, and we can only relate to you what your health insurance company has told us regarding your benefits. We cannot guarantee that the quote of benefits was correct or that the insurance company will pay what they have said that they will pay. In fact, insurance companies tell us that a quote of benefits is not a guarantee of payment and that payment decisions are made when the claim is processed (i.e., AFTER your appointment). In other words, even if the insurance company representative tells us that you will only have to pay a $25 copayment to see us, they can still decide to apply the entire bill to your deductible later when they process the claim, resulting in you having to pay $75 to $500 or more, depending on the extent of services you received from us. Unfortunately, we have no control over what portion of your bill your insurance company will pay.
Is my clinician in-network with my health insurance?
The clinicians at Etheridge Psychology are in-network with multiple insurance plans. Some of our clinicians are in more networks than others. While we do hold contracts with various insurance companies, we have found that there are specific plans within insurance companies that may not consider us as in-network providers. For example, we are in-network with Blue Cross and Blue Shield of North Carolina. We accept many BCBS plans, including most out-of-state BCBS plans. If you are looking for counselors that accept BCBS in Cary, all of our therapists are in-network. We are not, however, in-network providers for individuals who have a Blue Local plan, even though we do have a contract with BCBS. We cannot guarantee that the clinician you see at Etheridge Psychology is considered to be an in-network provider for your specific plan, even if we have a contract with them.
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. That is the patient's responsibility. We highly 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?
Note: If you are coming for psychological testing, you should give the representative more details, such as the reason for the evaluation and/or the type of testing. Health insurance companies may not cover testing for learning disorders, testing that is requested by a court or other legal system, and sometimes even specific mental disorders like ADHD are not covered. If this is the case, you will have to pay for your evaluation in full at our self-pay rates. Psychological testing can be expensive, so you may wish to consider whether you can pay the balance if your insurance company decides not to cover it.
Also note: Some insurance companies use a separate company for mental health benefits. Ask whether this is the case with your policy and whether your clinician has to be in network with that company for services to be covered. For example, your clinician may be in-network with your BCBS plan, but your mental health benefits may fall under a separate company like Beacon or Magellan. If your clinician is not in network with the mental health portion of your health insurance, the services will not be covered.
I've been coming to Etheridge Psychology for a long time. I used to just pay a small copayment; why do I have to pay a lot more this year?
We have noticed that many patients' insurance plans changed this year. Whereas last year's policy only applied services like hospital admissions to deductibles, this year's policy has likely included more services under the deductible umbrella. As millions of Americans have learned in recent years, premiums continue to rise, and out-of-pocket costs per healthcare service have risen as well.
While we have no control over how much your insurance company requires you to pay out-of-pocket for services with us, we share your disappointment that mental health services are costing you more this year. We feel strongly that mental health care should be widely available and accessible without regard to ability to pay. If you cannot afford our services, we can provide referrals to lower cost community mental health care services.
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 you must pay that amount directly to Etheridge Psychology. Per our contracts with insurance companies, we cannot forgive that balance, as you have received credit for that amount on your deductible as having been paid out-of-pocket. As stated in our Financial Policies, we ask that you pay the estimated amount at the time of service. After the claim is processed, the insurance company will give us an exact amount that was applied to your deductible. If you still 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 call us and request one. For payment plans, we require that a credit or debit card be placed on file and that payments be automatically withdrawn each month until the balance is paid. We will work with you to determine the amount each month that you can afford. If one automatic payment does not go through, we will attempt to call you to correct the problem. If we cannot reach you, the balance is automatically forwarded to collections. 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, appealing 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 from your health insurance company. Call the phone number on the back of your insurance card. 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 ask if there is a reference number for the phone call that you can write down. This information may help if the claim is later denied or underpaid. We also recommend that you read all the materials given to you when you got your health insurance. If you do not have that information, your health insurance company should be able to get it for you.
We hope that this information has been helpful.