How To Verify Insurance Benefits For Your Professional Services

Nov
8
2012
Have you ever started seeing a client only toImage of How to Verify Insurance Benefits of Your Services find out after four sessions that her insurance company will not reimburse her for your professional services? 
The easiest way to avoid this scenario is to verify benefits before your see her.  One way to do that is to create a checklist of questions for you to complete on the telephone prior to your first appointment.  Here is an example of a telephone script that you might choose to use with every potential new client . . . .
Jane, it’s important to me that neither you or I are caught off guard concerning money matters and paying my fees.  If you plan to seek reimbursement from your insurance company for my fee, I would like to assist you in verifying your insurance benefits.
  • What is your date of birth?
  • What is the name of your insurance company?
  • What is your policy number?
  • What is your group ID number?
  • And, what is the phone number of your insurance company?”
All of this information should be easily found on your potential client’s insurance card.  After obtaining this information, I recommend that you place a phone call to the insurance company (with your client’s permission, of course).  And, here is what you might want to say to them . . . .
  • I am calling to verify the insurance benefits of Jane Doe. Her date of birth is . . . .
  • Does she have benefits that cover outpatient mental health counseling?
  • What services and treatment protocols are excluded from her benefits?
  • What is her deductible?
  • Has her deductible been met?
  • Are there diagnoses that this policy will not cover?
  • How many sessions per calendar year does her plan cover?
  • How many sessions can she still access for this calendar year?
  • Am I on your provider panel?
  • If not, how much do you pay for services provided for an out-of-network provider?
  • Is there a limitation on how much you will pay me per session?
  • Is a referral from Jane’s primary care physician required?”
If you are going to file on your client’s insurance . . . or she is going to file on it herself, it would behoove you both to have as much of this information as possible before you get started on your work together.  An insurance script such as this makes sure that you or your client have not forgotten to inquire about these details in the haste to move on to your clinical work.
What have I left out of this script that can help other therapists in verifying insurance benefits?
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Comments

  1. Am I glad you have a “PrintFriendly” tab, Tamara! I just sent printed this up and, if I get on any insurance panels, will be using this and will offer it to my clients who are verifying their out-of-network benefits.

    Thanks for helping to streamline what can sometimes be a complicated, confusing part of a private practice!

    • Barbara! It’s so nice to have your voice here! (Can you tell that I’ve been thinking about our “systems and organization” conversation?) Thanks for sharing this with others who can benefit from it!

  2. Hi Tamara,
    Very helpful information indeed! I have a question for you. I am a Medicaid provider as I see clients referred to me by DPHHS. Although I am happy to help clients who cannot pay my customary fees, if I were to fill my book with clients who use Medicaid, I would literally cut my income in half of what therapists charge in my area. My idea is to devote a percentage of my practice to clients who need to use Medicaid to pay for my services. Can you think of a way to answer the question, “do you take Medicaid?” without telling a client, “yes, but my allowable for this insurance is full?” I’m not sure about the ethics or problems associated with this and wonder if anyone out there has any ideas. Thanks!

    • Hi, Linda – When I started to divest my practice from insurance and managed care, I did so gradually by setting aside a certain percentage of my practice for that purpose. When clients called asking if I was a provider or would work directly with their insurance company and my slots for those were already filled, I typically responded by saying “I set aside a percentage of my practice for your company but they are full right now. I would be happy to work with you if we can schedule your out X weeks or I can refer you to a different provider that I trust.”

      A different way to handle this is to inform Medicaid (or other managed care companies) that you are only available on Mondays (or whatever days of the week work for you) or at certain times of the day to handle their referrals. Then, when clients call and all of your slots on Mondays are filled, you can honestly say that “The earliest I can get you in is in two weeks” (which is your next “managed care Monday that is available). This strategy, by the way, is no different than offering a limited number of reduced-fee scholarships or deciding to donate 10% of your profits to your local church or charity.

      From a risk management perspective, I believe that mental health professionals’ Codes of Ethics address the need to give back to your communities. And, I know of no laws that specifically address this issue (although admittedly I am not an attorney). The only thing related to this that I would caution you about is making sure that you are keeping Medicaid (and other managed care companies that you contract with) apprised of any changes that you may make that differ from your original contract. For example . . . if you originally indicated that you can see their clients Monday through Friday from 8 a.m. to 8 p.m. and you are now choosing to restrict those hours, make sure that you notify them in writing of those changes.

  3. I believe we need written permission to speak with the insurance panel (release of information) in California.

    Best regards.

  4. Thank you for this info! I am just starting my practice and may start to see some clients who want to use their insurance. So helpful!

  5. ” Has her deductible been met?” Is a really important question to ask. Thanks for putting that in there, Tamara. I have been amazed by the amount of clients who don’t understand what the deductible means and how this can affect payment of services, in terms of what they pay per session. I’ve had to educate more than one client about this issue.

    • Kudos to you, Aaron, for taking the time to educate your clients about their benefits. It’s not something that most students of mental health are taught and our clients are typically less informed than even we are. However, as part of the informed consent process, it is incumbent upon us to help our clients understand what the financial and emotional consequences and benefits may be. For those of you that repeatedly find yourselves explaining these things, I would encourage you to “systematize” and streamline this process by creating handouts or including explanations (as much as possible) into your disclosure statements.

      • I’m new to this blog and new to starting up a private practice. Thank you for all of the great information and dialogue; It has definitely helped! Do you have any examples or handouts you have found helpful when discussing out of network policies, deductibles, etc… I want to fully understand what I’m talking about before I am explaining it to others :).
        I feel fortunate to have tumble upon this site. Thanks again.

  6. Great Post–
    We have developed a page to be filled out just for this purpose and it really helps. Letting people know before they walk in the door has almost eliminated difficulties over financial misunderstanding.

    Besides the things you mentioned and deductible Aaron mentioned, making sure you ask insurance about copay and coinsurance (good luck explaining that to the client) and very important– is there other insurance that covers their mental health and which is primary. A decision you have to make at that point is if you will file both or just one.

    • Hi, Lynn! Welcome to Private Practice from the Inside Out and thanks so much for taking time to join the conversation! My experience has been the same as yours. Although I no longer work directly with insurance companies, I have found that when clients are fully informed, they are able to make the right choices for themselves.

      I don’t know about psychologists, psychiatrists, or social workers but professional counselors are taught that beyond assessing and treating pathologies and symptom management and community support, it’s a major focus of the counseling profession to empower clients by providing both advocacy and education. A simple and direct conversation such as this is one way that clients can make better choices for themselves.

      Lynn, I would love to see a copy of the page that you guys use for this purpose. And, I’ll be amending mind to include a question about coinsurance, too! Thanks so much for the suggestion!

  7. Deborah Johnson says:

    This is an excellent discussion. Thank you for posting!

  8. Very detailed information Tamara! Thanks! I usually forget to ask some of these critical questions.

  9. I’m a child therapist and I always remind parents to verify whether or not their managed care provider covers psychotherapy for children. I work with children as young as three and occasionally a plan has restrictions on the age of the child or that services can only be provided with a parent in the session with the child.

  10. Hi Tamara,

    Thanks for sharing this! It will definitely come in handy and I’m glad you shared it with all of us here.

  11. A really late post, but I’ve chosen to accept insurance, and was recently accepted as a Medicaid BH Provider- through Value Options.. Crazy I know, it took 8 months, but I did it so consumers in my rural mountain community have a choice- besides the community mental health center!
    Anyway, I have access to insurance company websites, and can usually find most of this information on those provider sites. It makes it much easier when I have my assistant help me run benefits!

    • Stacey, thanks for catching us up on your decision! So happy this is working out well for you! Hope you’ll let us know about any “short cuts” and “lessons learned” on your journey!

  12. We do this as a routine and its saved me a lot of headache. Our billing professional verifies everyone before their first visit. Sometimes behavioral health ,may be carved out to a different plan or not have mental health benefits altogether. It saves a lot of confusion and headache later.

    • YES! It can save you time and money, too! If you choose to work directly with insurance / managed care, it’s important that as a business person you know what to expect. And, if you decide not to work directly with insurance / managed care, it’s empowering for your client to learn to ask these same questions. They no one is caught off guard – assuming that money will be coming when sometimes it won’t!

  13. Tamara great set of questions. I will add that while I am on the phone I will ask if an authorization is needed and being the provider they usually will allow me to set it up. I also will get the benefits with their co pay so I can let my clients know before their first session. And lastly since you don’t want to call back I ask them for the claims billing address so I can make sure it gets to the right place.

    • Hi, Maureen! Great additional tips! Thank you so much!

      • Hi Tamara,

        I’ve been doing this for years, using the above questions plus Aaron’s re:copay. I first used a billing co. but then found that using a printed out Verification of Insurance form it took little time. If I haven’t already gotten the info from an initial phone contact with the client (they can’t find their insurance card, don’t know their partner’s ssn, etc.), I have them fill out the form in the waiting room, telling them to come at least 15 minutes early. If anyone would like a copy of my form, I will email it directly. Please contact me at Claudia.trevithick@gmail.com.

        • Claudia, thank you so much for sharing your experience! I’m hoping to see a copy of your form, too. Having your clients come early to complete is is a great idea and something that we all have to do in our physician’s offices anyway so I know your clients don’t think twice about it. for those of you who choose to work with insurance, this is a step that you must take – whether you gather it on the phone or in your office – to keep from ending up in a financial mess.

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