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Insurance Responsibility

Overview

At River Oaks Psychology, we strive to provide a smooth experience when it comes to navigating the complexities of insurance coverage. Our providers are in-network with a wide array of insurance companies but not all providers accept the same insurances, so you must contact us by submitting this form, calling 248-717-1232, or by emailing hello@riveroakspsychology.com to determine if we will be able to accept your specific insurance. 

We act as a liaison between you as the patient and your insurance company. Essentially, we are the middle person between you and your insurance company. We submit claims on your behalf to your insurance company and we are legally obligated to follow the outcome of the claims. This means we don’t have a choice in deciding what your insurance will cover. Your insurance company determines the cost of your treatment. 

In a perfect world, we wish that insurance companies would always cover services for you 100%. We know how important treatment is. But unfortunately, that is often not the reality. Your insurance company will stipulate the cost of your appointments and we will have to legally abide by whatever instructions your insurance company indicates on the claims when they are returned to our office. We completely empathize with how frustrating insurance can be and we want to empower you to understand the full details of your coverage before beginning services. 

Understanding and knowing the details of your insurance coverage is ultimately your responsibility as the patient. YOU are responsible for calling your insurance to determine your out-of-pocket fees. This ensures that you did your due diligence to minimize any potential discrepancies when the claims are returned to our office.

We URGE you to familiarize yourself with your insurance plan, including its coverage for telehealth mental health services, any deductibles, copayments, or coinsurance requirements, as well as any limitations or restrictions that may apply. This information will help you make informed decisions about your treatment and financial obligations. By being knowledgeable about your insurance details, you can make the most of your treatment experience and ensure a smooth billing process.

Why am I responsible to know my coverage?

Understanding your insurance coverage is an important responsibility for several reasons:

Financial Planning:  Knowing your insurance coverage allows you to plan and budget for appointments effectively. It helps you understand your out-of-pocket expenses, copayments, deductibles, and any other financial obligations associated with your services.

Informed Decision-Making:  Understanding your insurance coverage empowers you to make informed decisions about your treatment options. It allows you to explore the providers and services that are covered by your plan, ensuring that you receive the appropriate care within the scope of your coverage.

Claim Outcome:  We act as a facilitator between you and your insurance company, as we submit claims on your behalf. However, we do not have control over the final outcome of the claims process. The approval or denial of claims is ultimately determined by your insurance company based on their policies and guidelines. By being informed about your insurance coverage, you can better understand the potential outcomes of the claims process and be prepared for any potential financial responsibilities. 

Avoiding Surprise Bills:  Being aware of your insurance coverage helps you avoid any unexpected costs or surprise bills related to services. It allows you to plan ahead, inquire about any limitations or restrictions, and know exactly what to expect. 

Advocating for Yourself:  Having knowledge of your insurance coverage enables you to advocate for your own healthcare needs. If you encounter any issues or discrepancies when your insurance claims are returned to us, being informed about your coverage helps you address these matters effectively.

Coverage Limitations:  Understanding your insurance coverage helps you become aware of any limitations or restrictions that may exist. This includes the number of sessions covered, any pre-authorization requirements, or specific conditions for coverage. By knowing these details, you can better plan your mental health treatment journey and ensure you receive the appropriate care within the limits of your coverage.

Network Providers:  Knowing your insurance coverage helps you identify providers who are in-network providers. In-network providers typically have negotiated rates with your insurance company, which can result in lower out-of-pocket costs for you. By understanding your network options, you can choose a provider who is covered by your insurance and maximize the benefits available to you.

Changes in Coverage:  Insurance coverage can change over time due to policy updates, employer changes, or other factors. Staying informed about your insurance coverage allows you to stay up-to-date with any changes that may affect your services. It ensures that you are aware of any adjustments in copayments, deductibles, or covered services, allowing you to plan accordingly.

Our Insurance Policies

Potential Insurance Discrepancies

As a courtesy to all patients, we will attempt to obtain an estimate of your coverage information by calling your insurance provider prior to scheduling your first appointment. Please be aware that in some rare cases, incorrect information is provided to us by insurance representatives due to ambiguity or misinterpretation of your coverage. 

This becomes apparent only after we submit your claims to the insurance and receive the processed claims in return. Unfortunately, it is impossible to be 100% certain of your insurance coverage until after the claim is submitted and returned from your insurance company. 

Upon receiving the processed claims, if there is any discrepancy in the coverage details we initially communicated to you, we will investigate it further. After investigating the discrepancy, if the outcome from the insurance is that the processed claim is accurate, you are financially responsible for whatever the processed claim indicates. We legally have to abide by the outcome of the claim. It is not our choice. We hope to never have discrepancies, but we want you to be aware of the possibility.

Therefore, you need to verify your coverage and ensure you fully understand your coverage details prior to beginning services. Calling your insurance company directly to verify your telehealth coverage details yourself prior to treatment is required in order to minimize potential discrepancies. Again, this is your personal responsibility. River Oaks Psychology only serves as the middle person between you and your insurance company.

What If My Insurance Fails to Pay?

You are financially responsible for the cost of your services in the event that your insurance company fails to provide payment for services. This means if your insurance company unexpectedly fails to provide payment, you are responsible for paying out-of-pocket for the services you received.

This also applies retroactively. For example, if your insurance company issues payment to River Oaks Psychology, and then later requires us to return the payment to them because your coverage was terminated prior to the date of payment stopping, you are responsible for paying out-of-pocket for the services you received. It is uncommon for insurance companies to require us to retroactively return payments, but this can and does happen in some cases when payments were issued to us by mistake. To prevent this from happening, please communicate with your insurance company about your coverage details. It is extremely important for you to call your insurance directly to verify your telehealth coverage details.

Patient Insurance Changes

If you are receiving ongoing services from River Oaks Psychology and you have a change in your insurance coverage, it is your responsibility to let us know. When this occurs, we will once again attempt to call your insurance to find out your coverage details prior to further appointments. However, it is still your responsibility to contact your insurance company directly and determine your telehealth coverage. Again, this ensures that you did your due diligence to verify your coverage and out-of-pocket costs.

If your insurance changes and you fail to let us know, you are financially responsible for the cost of your services in the event that your new insurance provider does not provide payment for your services.

How Do I Contact My Insurance?

1.  Gather your insurance information, including policy or member ID number, and have it readily available.

2.  Locate the customer service contact information provided by your insurance company. This is typically found on the back of your insurance card or through their website. 

3.  Ensure that you have the following information on hand:

  • Your Member ID number, policy number, group number, or any other insurance details
  • NPI number of the provider (or the provider’s clinical supervisor) who you plan to receive services from. An NPI number is a national provider identification number. Every healthcare practitioner has one assigned to them. Please ask us for this number. Depending on the provider you plan to see, you may need to provide their NPI number or the NPI number of their supervisor. This is important. We are happy to provide you with this information. 
  • Your Date of Birth, or the Date of Birth of the policyholder on your card (if you are covered on the insurance policy of a parent, partner, or someone else). 
  • Your insurance company might also ask you about the CPT codes (billing codes) that will be billed to the insurance. The CPT codes that we utilize here for therapy at River Oaks Psychology include 90791, 90837, 90834, 90832 for individual therapy and 90791 and 90847 for couples or family therapy. For medication services, we use 90792, 99213, 99214, 90833 and 90836.

4.  Make a list of questions you plan to ask your insurance company. Example questions are listed below. 

5. Call the customer service line and listen to the available options. Look for an option related to member services, benefits, or claims. Select the appropriate option to speak with a representative who can assist you with your inquiry.

6. Introduce yourself and let the representative know that you have questions specifically related to telehealth mental health services.  Ask about the coverage and benefits for telehealth appointments. Inquire about deductibles, co-pays, coinsurance, or any out-of-pocket expenses associated with these services. Ask if there are a limited number of sessions that will be covered.

7. Take detailed notes of the information provided.

8. If you encounter any difficulties or need clarification, politely ask the representative to explain further or connect you with a supervisor who may be able to provide more assistance.

Your insurance company may use the terms: mental health services, psychiatric services, behavioral health services, medical nutrition therapy, tele-therapy, tele-mental health, or related terms. 

Remember to prioritize your comfort and ensure that the information you receive aligns with your needs. It’s important to have a clear understanding of your insurance coverage to make informed decisions about your mental health care.

You may also be able to visit the insurance company’s website and look for a member portal or customer service section. Many companies offer online tools to assist with claims, benefits, and coverage inquiries. 

Example Questions to Ask Your Insurance Company

  • Does my insurance plan cover telehealth mental health services?

  • Are there any specific requirements or limitations for accessing telehealth services?

  • What is the coverage for telehealth appointments compared to in-person sessions?

  • Are there any deductibles, co-pays, coinsurance, or out-of-pocket expenses associated with telehealth services?

  • How close am I to meeting my deductible? What happens after my deductible is met? 

  • Do I need prior authorization or a referral from my primary care physician to receive telehealth mental health services?

  • Are there any restrictions on the number of telehealth sessions allowed within a specific time frame?

  • Can I choose any mental health provider for telehealth services, or are there specific network providers I need to see?

  • How can I find out if a specific provider or practice is in-network for telehealth services?

  • Are there any specific diagnoses or conditions that are excluded from telehealth coverage?

  • Do I have telehealth coverage for individual therapy and couples or family therapy?

  • What about medication services? Do I have telehealth coverage for medication office visits? 

Remember, these are just examples, and the specific questions may vary depending on your insurance plan and personal circumstances. It’s important to ask questions that are relevant to your coverage and to clarify any uncertainties you may have. We urge you to reach out to your insurance provider directly to get accurate and personalized information about your telehealth benefits. You’ll want to have a thorough understanding of your coverage to make informed decisions about your mental health care.

Insurance can be tricky… but you are your own best advocate!  

Take things one step at a time.