health insurance claim question

May 19, 2022 7:37 AM

I fear this is a dumb question but I'm asking anyway.

After many months and several therapists I have finally found one that I have clicked with. My employer-sponsored health insurance covers therapy.

However. My therapist doesn't accept insurance.

(Neither does my psychiatrist.)

Can I try to submit a claim for my therapy appointments? I have invoices and receipts for my weekly payments.

I would submit these receipts for reimbursement through my FSA but honestly I would blow through my FSA money in two months if I did that. I usually use my FSA for prescription copays, chiropractor appointments, and my psychiatrist fees. If I max out my FSA next year my take-home pay won't allow me to cover my portion of our bills (given deductions for insurance and 401K).

Please forgive my ignorance, I have no idea how this works and I hate our broken health care system in the US.

posted by nayantara to Health & Fitness (5 answers total)

Assuming you have out of network coverage, you should be able to submit the claims as such to get some reimbursement -- you can request a superbill and use that to submit your claim (my understanding is that you need to have a diagnostic code and the specific service provided on the invoice in order to have the claim go through which are typically not on standard invoices). I submitted mine online through my insurance portal and found it fairly straightforward. This should also be something your therapist can give you guidance on, if necessary.
posted by sm1tten at 7:49 AM on May 19, 2022 [4 favorites]

For medical care that doesn't take insurance, I submit my receipt with a claim form directly to the insurance company. Your insurance may contact you or the healthcare provider to make sure it is coded correctly. You may want to make sure that your therapist meets the requirements to be covered by insurance in advance.

When I put in the claim, I can choose for the insurance company to pay my doctor directly or send me the payment. I usually have them send it to me since I've already paid my doctor. The payment is at the "out of network" rate (not sure if you have a network).

When the claim is processed, I take the EOB (explanations of benefits) that shows how much the total cost was, how much insurance paid, and how much I paid, and submit it to my FSA. Then I will get how much I paid out of pocket reimbursed to me.

US healthcare is a mess and I hate, hate, hate this process. And I'm saying this as someone who has really good healthcare coverage!
posted by jraz at 8:07 AM on May 19, 2022 [1 favorite]

You can call your insurance company and ask them what kind of coverage you have for out of network (OON) services. HMO style plans don't cover any OON services. Preferred provider plans (PPO) usually do cover as % of your charges (up to a max of what they consider usual and customary - which may be less than the actual amount). There is also usually a separate (and often higher deductible for OON charges.

So you want to ask:
- do I have OON coverage?
- what is the deductible?
- once I reach the deductible, what is the copay (a fixed $ per service) or co-insurance (%)?
- they probably won't tell you the maximum but they might (maybe) tell you if your therapist fee is within that limit
- how do I file a claim? (with my plan there is just a cover sheet that I use to send in the forms I get from the doctor)

Also, you usually need to submit a form that is called a superbill that includes a diagnosis, place of service and procedure code that may not be required when you do your usual FSA claims. Even if your therapist wants nothing to do with insurance, it is very reasonable that they give you a statement that includes this information that you need (and they may be set to do it already) Or everything necessary may be on the receipts that you get already.
posted by metahawk at 9:55 AM on May 19, 2022

Best answer: You need a detailed receipt (your therapist is surely used to this). Call and ask your insurance company how to proceed and how to file a claim for reimbursement. I do this it’s a mild pain, but I also get the money! Seriously call your insurance. I would have saved myself months of frustration if I had started with that.
posted by Bottlecap at 11:51 AM on May 19, 2022

You can generally do this if you have a PPO plan. Technically this is why people choose PPO plans, because of the flexibility. The reality is that insurance makes it really hard to get OON covered. I have to keep a spreadsheet of my visits, when I submitted, when I last called to check on the reimbursements etc.

You should first call your insurance and find out what the limitations are. For some specialists, they won't cover if there is an in-network person within X miles (this was my issue with my last insurance trying to get PT covered). Sometimes for mental health, they will only cover therapy for certain diagnoses. I had one insurance that would only cover it if my diagnosis was "severe" - depression was considered severe, but anxiety wasn't. (Depending on your relationship with your provider, they may or may not be amenable to adjusting your diagnosis code.)

The other thing to know is that they will only cover a percentage of the "allowed amount." And of course only after your OON deductible is met. So for example your therapist bills you $150. But insurance may say the allowed amount is $60, and their 80% coinsurance coverage reimburses you $48. Nothing to sneeze at, but just don't expect them to cover the whole thing.

Some employers offer a "care navigator" service. If yours does, use them. They are great at dealing with this for you. My employer offers a company called Rightway. I can call or chat them, and they will literally call and sit on the phone with my insurance for me.

BTW once you've finally squeezed your reimbursement out of the insurance, you can submit your EOB to the FSA and get reimbursed by FSA for the balance.
posted by radioamy at 8:46 PM on May 20, 2022