Navigating Insurance
Boston Professionals Counseling, LLC is not an in-network member of health insurance panels. Our preferred method of payment is directly from our clients. We will make every effort to assist you with your health insurer and any available out-of-network benefits through which you may be reimbursed. We will also help you determine the specific coverage your policy allows for outpatient Mental Health and go through the various payment options with you. In addition, we will assist in providing information your health insurer requires to provide reimbursement, always only with your written consent.
Many of our clients prefer to avoid using their health insurance despite any potential cost savings. The primary benefit of self-payment is that it prevents the invitation of a third party into treatment that necessarily occurs when health insurance is utilized. For insurance to pay, therapy needs to be considered “medically necessary,” which requires a diagnosis of a medical condition. This creates a record that can be considered in future insurance decisions.
Most often, a health insurer will assign a case manager who wants to know particular details about a client and the particulars of the treatment. They may and often do call the therapist for updates, and can make payment for treatment contingent upon disclosure of such information. Many clients find this intrusive and upsetting. Even after giving up privacy and obtaining a medical diagnosis, the insurance company can decide not to pay for treatment if they do not agree that it is medically necessary.
Sometimes, Boston Professionals Counseling will utilize a sliding fee scale based on a client’s financial need. Each case is decided and agreed upon together with the client based on the particular circumstances.
Obtaining Reimbursement
The process for obtaining reimbursement from a health insurer is usually relatively simple if you have an out-of-network benefit. Each insurer has on its website an out-of-network benefit request or reimbursement form that is downloaded and filled out. We then provide you with an invoice showing payment for your sessions together with the appropriate insurance and diagnostic codes for obtaining reimbursement. Those forms are submitted to the insurer and the insurer reimburses an established out-of-network amount to the client. This process can take from one to four weeks.
There are very limited circumstances under which a person without a PPO plan or a plan that does not have an out-of-network benefit can obtain reimbursement for sessions. Those situations usually involve some sort of clinical emergency (such as suicidality or serious self-harm), or issues relating to continuity of care (when a client has seen a treater for a long enough period of time that it would be harmful to change because of network status). Through our experience, insurance companies will do everything in their power to avoid paying higher out-of-network fees and will exert pressure on the client to change providers to one in their network, and for whom they have negotiated a substantially discounted rate.
While we are happy to help a client for the benefits they’re entitled to and for which they’ve paid, such fights often end in frustration. However, when warranted, coverage has been extended and sessions reimbursed.
