Can I submit only some of my out-of-network expenses to insurance?

September 24, 2023 5:28 PM

I was seeing a therapist out-of-network for both individual therapy and group therapy. When I submitted it to my health insurance, I noticed that when they were on the same day my insurance only reimbursed for part of the (cheaper) group appointment and nothing for the (more expensive) individual appointment. There were a few other times this happened that I haven't submitted yet. Can I submit only the individual appointment and not tell them about the group appointment or will that risk getting me in trouble with the insurance?

Once I found out, I avoided having any more group and individual appointments on the same day, but there were a few times before I found out that I haven't submitted yet. If I only submit the individual appointments, the insurance will reimburse a higher amount for the more expensive appointment. Since it's out-of-network, I feel like it's up to me whether I submit any of it or not. Is that correct? Does health insurance have rules about that?

posted by Gravel to Work & Money (10 answers total)

That doesn’t sound right to me — submitting more expenses for reimbursement shouldn’t reduce the overall amount of money you receive from your insurance.

You need to get the full “explanation of benefits” document from your insurance, read the coverage details, and understand how that maps to the reimbursement amounts you’re getting. If it doesn’t make sense even after reading that document, it’s worth a phone call to your insurance provider.
posted by mekily at 6:03 PM on September 24, 2023 [1 favorite]

I feel like it's super ordinary to have multiple medical events on the same day that require reimbursement -- like a doctor's visit that also generates lab tests, for example. Going to the eye doc where you have to pay for an exam but also a new pair of glasses. Or a visit to the ER and all the various kinds of charges you can rack up in an hour. Maybe call them first to ask if it's just oversight?
posted by BlahLaLa at 6:28 PM on September 24, 2023

Response by poster: I assumed it was an oversight at first too, but when I called, the customer service person said it was correct. Maybe since it's two therapy appointments with the same therapist on the same day? It seemed absurd to me, but I didn't have the energy to pursue it further.
posted by Gravel at 6:45 PM on September 24, 2023

Yes, it's very likely being denied by the insurance company's claims adjudication software as being duplicate billing for the same service on the same day, especially with both appointments being with the same therapist. When multiple claims of the same type of service happen on the same day, the claims need to be submitted with an extra modifier code to essentially tell the insurer "Yes, this wasn't a mistake, these are two different services." Since the therapist is out-of-network, they wouldn't necessarily be familiar with the specific billing requirements of your insurer, or maybe the two claims were sent to you independently without the therapist realizing that they were on the same day and would need some extra coding.

I'm not a coding expert, but my cursory googling indicates that you'll probably need to get your therapist to send you (or the insurer) revised claims using CPT modifier -59. This section of an article on Find-a-Code pertains to physical therapy rather than mental health therapy, but it otherwise lines up with your situation, down to the group therapy claim being paid and the individual therapy claim being denied:

Billing for both individual (one-on-one) and group services provided to the same patient in the same day is allowed according to Medicare and Current Procedural Terminology. However, the CPT and CMS rules for one-on-one and group therapy must both be met. Of particular importance is the fact that the group therapy session must be clearly distinct or independent from other services and billed using a -59 modifier. These rules require the group therapy and the one-on-one therapy to occur in different sessions, timeframes, or separate encounters that are distinct or independent from each other when billed on the same day. The Physician would use the -59 modifier to bill for both group therapy and individual therapy CPT codes to distinguish that the two coded services represent different sessions or separate encounters on the same day. Without the -59 modifier, payment would be made only for the lower-priced group therapy CPT Code, in accordance with CPT/CCI rules.
posted by bassooner at 7:05 PM on September 24, 2023 [6 favorites]

I was previously told when going to couples and individual counseling at the same practice (but with different therapists) that they could only submit for one or the other. Not sure if this was a quirk of my insurance or is a standard practice, but that may be information to pursue
posted by raccoon409 at 7:07 PM on September 24, 2023

A number of CPT codes (which is what the insurance looks at for what to reimburse and how much) have restrictions on them for what other CPT codes are allowed to be billed on the same calendar day. Things like follow-up labs are generally allowed; things that look like duplicate appointments or billing for stuff that should have been covered in the first appointment may not be. Like bassooner said, there are sometimes modifiers that can fix this (but not always).

If your therapist takes insurance but not your insurance, they might know what to do to fix it. If they don't take insurance at all (and therefore may be unwilling to talk to the insurance company on your behalf), you probably want to call the insurance company and see if they'll explain what you what's going on.
posted by lapis at 8:55 PM on September 24, 2023

I am a therapist, I am not your therapist. We are not allowed to bill for two appointments with the same person on the same day. A person is also not allowed to have a therapy appointment and a psychiatric med management appointment on the same day. Both of these are because insurance will only cover one appointment, which leaves the client on the hook for the cost of the other appointment. I don't know why this is the rule, but I do know this is the rule.
posted by epj at 9:53 AM on September 25, 2023

Best answer: Can I submit only the individual appointment and not tell them about the group appointment or will that risk getting me in trouble with the insurance?

There's nothing wrong with doing this since you're out-of-network. Right now, your framing implies that the insurance company will think you're lying by omission to to get a higher reimbursement; but really the insurance company is just going to think you don't need help with paying for group sessions, and that's as deeply as they're going to think about it (if even that much).

It may feel like it doesn't make sense that they would give you MORE money back than for what you were previously submitting, and that's because health insurance doesn't, in fact, make a lot of sense. The system is very jerry-rigged and built-as-we-go, so it's accreted a lot of practices and compromises that sometimes result in weird circumstances such as this you've encountered.

So yeah, go ahead and submit only the individual session requests.
posted by obliterati at 10:04 AM on September 25, 2023

Best answer: No, you will not get in trouble. As long as you are happy paying out of pocket, you have the right to choose not your use your insurance for certain services/procedures. And you can do that session by session if you want.

It will be simplest if the individual and group sessions are on separate statements so you can just submit the ones that you want to be reimbursed for. If they are on the same statement, I would black out (solid black line making what is written under it unreadable) the services that you don't want remibursement for.
posted by metahawk at 4:32 PM on September 25, 2023

Response by poster: Thanks everyone! Lots of helpful info! I feel more comfortable submitting only the individual sessions now.
posted by Gravel at 8:49 PM on September 25, 2023