UNDERSTANDING INSURANCE + RESOURCES
 

On this page you can find brief explanations of the following terms and concepts:

• Superbills

• Out-of-network

• Premera specific resources

• HSA accounts

• Recent letter to current clients about my decision to longer contract with insurance carriers

Superbill

For a brief overview see this description from Simple Practice.

A Superbill is essentially a receipt for behavioral health services. This is used to help clients get reimbursement for services. For example, when you attend a mental health therapy appointment there is typically a “service code” and “diagnostic code”, in addition to the date, and the amount you paid. If you met with a therapist for 53+ minutes they would likely use service code 90837, which just means you attended a psychotherapy session with a licensed therapist. The diagnostic code references your clinical diagnosis, which should have been discussed with your provider.

When you ask your therapist for a Superbill, and share it with your insurance company, know that you are disclosing personal health information (PHI). Please review privacy practices with your insurance carrier if you would like to better understand how they manage PHI.

Please read the following section to better understand what to expect on reimbursement.

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Out-of-network

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An out-of-network (OON) provider is a healthcare professional (therapist, doctor, social worker, etc.), whom does not hold a contract with your insurance carrier. OON providers are paid directly by clients or patients. They are not beholden to specific rules dictated by the insurance company, such as session time limits, service codes utilized, or diagnoses “covered”. Patients / clients can submit claims and request reimbursement after services have been rendered. The amount for which someone is reimbursed will be dependent on the carrier and the specific plan. For example, not all Premera plans have the same coverage. Each plan has a unique policy.

These are some questions you can ask your insurance carrier when exploring the option of working with an OON provider:

 

1.  Do I have OON coverage for behavioral health?
 

2.  What is my OON deductible? (This part is really important to clarify since many plans have a           DIFFERENT OON deductible)
 

3. Once my deductible has been met, at what percentage does my plan cover OON behavioral health

    services?

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Resources Specific

for Premera Customers

 

Mindful Care PLLC is located in the Seattle area and thus works with many clients who have Premera BCBS as their insurance carrier. Every plan, even when under the Premera umbrella, is unique. Even plans within the same company can vary greatly. Typically employees have a variety of plans to chose from. Below I’ve compiled some helpful tips and resources specific for clients with Premera who are wanting to better understand how to utilize OON behavioral health benefits

 

Customer service #s:

1. for members with employer-sponsored plans: 800-722-1471

2. for members with individual plans (If you bought your plan directly from Premera or

    WaHealthplanfinder.org): 800-607-0546

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Plan and benefit details can be found via the Premera Member Portal

Claim submission is often most stream-lined through the Premera app.

Premera Member Submitted Claim Form for Amazon and Subsidiaries

General instructions for requesting reimbursement from Premera BCBC

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Health Savings Accounts

 

The definition of a Health Savings Account (HSA) will vary from company to company. Often HSAs are pools of money your employer offers you as a benefit to flexibly cover costs that are not covered by your insurance carrier directly. This may be a co-pay, massage appointment, physical therapy, or any out of pocket expenses, including behavioral health care. It is always recommended to review your company’s policy for HSAs. Once you have deemed that your HSA can cover behavioral health services you then can give you account information, which typically works similar to a debit card, to your therapist. The therapist can then offer you a receipt as needed.

For a brief guide to understanding HSA, FSA, and HRA click HERE.

 

LETTER TO CURRENT CLIENTS

I will not be contracting as in-network provider with any insurance company. This is a decision I have not made lightly, but one thoughtfully guided by my personal values, and my ethics as a licensed therapist. Reading this letter it’s likely you have many questions. Below I offer you the basic facts up-front and then walk you through common questions and answers.

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Clients are required to pay my full session fee at the time of service:

• $150 for on-going 60 minute individual sessions

• $175 for 90 minute individual sessions

• $175 for on-going 60 minute couple/ family sessions

• $200 for 90 minute couple/ family sessions

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There are both benefits and challenges to seeing an out-of-network provider. First and foremost it removes a third party from having any say in your therapy services. It allows you and I, together, to make autonomous decisions about what type of therapy you receive, how long your sessions are, and the duration you wish to stay in therapy. Importantly, no longer contracting with insurance companies allows me to better ensure your privacy. Diagnosis information, notes from our meetings, and treatment plans are no longer readily accessible to your insurance carrier. Should we decide together that a formal “diagnosis” doesn’t serve you, I’ll no longer be required to give you one. This is especially relevant for those of you seeing me for issues related to relationship counseling or grief and loss (both common human conditions that don’t meet criteria for a “diagnosis”). I’m hopeful you and I will get to continue our work together with an enhanced sense of privacy, flexibility, and autonomy.

While there are many benefits to removing a health insurance company from our therapeutic relationship, I want to acknowledge the financial impact this may have on you. I’ve developed a list of FAQs below that will hopefully answer your most pressing questions. Please keep in mind that this change isn’t happening for a number of months, so we both have time to come up with a plan moving forward that will best suit your needs.

Though I cannot anticipate every possible outcome, I have identified what you may expect when working with an out-of-network provider:

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1. You cover the cost of therapy yourself, submit a receipt (Superbill) to your insurance carrier, ask for reimbursement, and get a portion of the fee covered.

2. Your employer provides an HSA or flexible spending account which you can use to cover the cost of therapy services.

3. You cover the cost of therapy yourself, submit a receipt (Superbill) to your insurance carrier, ask for reimbursement, and due to your specific plan your insurance carrier does not reimburse you, or only reimburses you for a small amount. 

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FAQ

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1. What exactly does it mean that you’ve “ended your contract” with my insurance?
 

This means I am no longer an in-network provider and am now considered an out-of-network provider.
 

2. Can I use my out-of-network benefits?
 

Yes! My choice to no longer contract with insurance does not mean you cannot utilize your out-of-network benefits. I would encourage you to call your insurance company and ask them the following questions:
 

• Do I have out-of-network coverage for behavioral health?

• What is my out-of-network deductible? (This part is really important to clarify since many plans have a DIFFERENT out-of-network deductible)

• Once my deductible has been met, at what percentage does my plan cover out of network behavioral health services? How much of Lina's fee will you cover? 

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3. Is there a way you, my therapist, can help me get reimbursed by my insurance carrier?
 

Yes. I am able to generate a special “receipt” called a Superbill, which you can then submit to your insurance company for reimbursement. Please note that included on this form will be a diagnosis. 
 

4. Now that insurance isn’t paying you directly, how will we handle billing?
 

I keep a credit card on file for all clients, and unless we make other arrangements, my automated system will charge your card the evening after our sessions. You’ll be charged my full fee the day we meet.

5. Once I submit a claim to my insurance company, when and how will I get a reimbursement?

The answer to this question will vary depending on your carrier’s policies. Typically the insurance company will mail you a physical check. As a general policy on my end, I do not accept payment from insurance companies directly when I am out-of-network. Typically there is an option when you are submitting a claim that lets you select “send payment to customer”. I’m happy to help troubleshoot this process with you!
 

6. I can’t afford to keep seeing you if I’m now responsible for paying your full fee up front. What are my options?
 

If you do not have out-of-network coverage, or paying my full fee is not an option for you, and prompts you to consider terminating therapy prematurely please talk to me directly. The plan we come up with will be individual to your needs, but here are some likely options:
 

• You and I agree to a reduced fee for a limited period of time.

• You and I spend the next few months thoughtfully transitioning you to another therapist who is in-network with your insurance company.
   

Again, I understand that paying for therapy services directly emphasizes the commitment and investment you have to yourself. I invite this change in my practice as an opportunity for you and me to clarify and reinforce therapy goals to ensure your time with me feels as valuable and useful as possible.

Please let me know if you have further questions or want help problem solving what this change will mean for you. I’m glad to e-mail on this topic, talk during our next session, or set up a time for a phone call.

 

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Good Faith Estimate

Under Section 2799B-6 of the Public Health Service Act, health care providers and health care facilities are required to inform individuals who are not enrolled in a plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage both orally and in writing of their ability, upon request or at the time of scheduling health care items and services, to receive a Good Faith Estimate of expected charges.

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. If you receive a bill that is at least $400 more that your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate.

DISCLAIMER: The Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.

To learn more and get a form to start the process, go to www.cms.gov/nosurprises

Please let me know if you have further questions or want help problem solving what this change will mean for you. I’m glad to e-mail on this topic, talk during our next session, or set up a time for a phone call.

With kind regards,

Elina Kogan, LSW, MFT

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