Forms & Insurance

Did you know that mental health providers are paid less than primary care providers by insurance companies? A recent report found that Insurers paid primary care providers 20%-50% more* for care than they paid mental health care specialists, including psychiatrists. Because of low reimbursement rates, many professionals in the mental health and substance abuse fields are not willing to contract with insurers. Especially the really good providers.

If you use your insurance to pay for therapy, you should be aware that your insurance provider has the right to know why you are going to therapy and the progress you are making. Which is why many of the more experienced and more established therapists have removed themselves from managed care panels.

On the back of the insurance card, there should be a toll-free number for questions related to mental health benefits. When calling, be sure to check coverage carefully by asking the following questions:

• What are my behavioral health (mental health) benefits?
• What is my deductible and has it been met?
• How many sessions per calendar year does my plan cover?
• How much does my plan cover for an out-of-network provider after my deductible has been met?
• Is approval required from my primary care physician?

• Insurance company may require you to meet a deductible prior to them paying for your sessions minus your co-pay. Call your insurance company to verify, so you can make an informed choice.
• If you are using your insurance to pay for therapy, you should be aware that they have they right to know why you are going to therapy and what progress you are making. Your insurance company has the right to audit your therapist’s files and notes and ask questions of him/her regarding your mental health issues.
• In order to access your insurance benefit, the therapist is required to diagnose you with a mental disorder. The record of this diagnosis will also become part of your Medical Information Bureau profile.
• Many of the more experienced and more established therapists have removed themselves from managed care panels. This may make it difficult for someone using their insurance benefits to find a particular specialty or a certain level of experience.

How do you get your insurance provider to work with an out-of-network counselor? Ask for a Single Case Insurance Agreement.

Insurance providers who offer single-case contracts will review potential agreements on a case-by-case basis. It’s important to note that the agreement is specific to the current episode of care and does not apply to care outside of this treatment episode.

What is a Single Case Agreement?

A single case agreement is a contract between a patient and their insurance company who has agreed to treat Kaleidoscope Behavioral Health as though they are in-network. With this agreement the patient pays the full session fee at time of service, and when the patient files with their insurance, they are reimbursed at the higher in-network rate.

A letter of medical necessity is an essential part of a request for services, and can be used in a wide range of issues. Maybe a physician has recommended therapy for a patient and the insurance company denies paying for an out-of-network provider. Or, a patient is hospitalized and his physician wants him to go to a specific behavioral health provider post discharge but the insurance company denies the request.

A letter of medical necessity, when being submitted to a private insurance company, should contain the information needed to convince the reader that the requested service is necessary to meet the medical needs of the person for whom the service is being requested.

In order to be effective, the letter of medical necessity should be written by a healthcare professional familiar with the requesting party’s medical condition. The professional should briefly describe their credentials and relationship to the requesting party. This professional may be a physician, a nurse, or other medical professional. However, note that most funding sources (aka insurance companies) require a physician’s letter as part of the funding request. Therefore, letters of medical necessity not written by a physician should be endorsed by a physician.

When a letter of medical necessity has been written, but services are still being denied, do yourself a favor and track it down so that you can make sure that the important parts are included. Most letters of medical necessity are not that well written or compelling, so insurance companies can easily deny the service.

> Sample Letter of Medical Necessity

> Request for Letter of Medical Necessity from your physician