Mental Health Billing question

[sweet2ndchance]

Would $400 per weekly 45 minute session with a licensed social worker with a therapy and counseling certificate who only does talk therapy (no CBT or psychoanalysis or diagnosing disorders or anything other than being a listening ear and offers the occasional platitude or book to read)sound reasonable to you? Or am I right in thinking that it sounds like they are milking insurance for all they are worth?

[Terabith]

I guess it depends on your location, but in most places around the country, that would be $100-200 a week.  

[maize]

Does insurance actually pay that? Most of the time what is billed and the amount insurance pays are entirely different.

[Joker]

Dd's psychologist has a professional degree (PsyD) and bills insurance 200 for our every other week visits. Price was the same when we went weekly. When we've seen therapists with certificates only it was less. I think it's way too much, but maybe could depend on where you're located and availability of other help.

[sweet2ndchance]

We live in a rural area where the median income is around $40k county wide and 70% of the school children in the area receive free lunches and are on Medicaid.

Yes insurance has been paying this clinic that much for weekly sessions.

$100 - $200 per session was what I remembered paying oop but that was just over 10 years ago.

[fairfarmhand]

Our insurance is billed about $80 an hour.

[NorthwestMom]

That sounds extremely high to me. 

[J-rap]

Here we might be charged $250 for an hour-long session.  $400 for 45 minutes seems really, really high.

[sweet2ndchance]

We are just now getting bill after bill for sessions dating back to last summer for $400 per session saying that we are liable for all of it because our insurance changed their policy last summer and will now only pay for 1 session per month. This is from the billing department not the insurance company. We haven't been able to get a hold of anyone useful from the insurance company yet. The itemized bills we are receiving show where insurance paid $400 for the first session every month and they are holding us liable for the other 3 per month.

Insurance had no problem paying for weekly therapy appointments in the larger city were we used to live but I'm not sure how much those other clinics were charging. We never had any billing problems from them. If we had known last year that a) they were charging this much and b) insurance wasn't paying for appointments then we would not have continued going despite the fact that I really need to be in therapy (I am diagnosed with PTSD, C-PTSD, severe anxiety, chronic depression, complex grief disorder and suspected Asperger's syndrome. These diagnoses were given in a psychiatrist's office 2 hours away) There is only this clinic charging $400 a session and one other clinic with a  6 - 12 month waiting list for a spot in our area. Everything else is 90 minutes to 2 hours away in the larger cities.

So far, the bills total almost $5,000. They will not pro-rate or sliding scale based on income for these bills. There are even a few dates on these bills that we are pretty sure we had to skip therapy that week because of scheduling conflicts and we always cancelled at least 3 days in advance but usually a week or more in advance so I know we weren't charged a "no show". They just billed insurance anyways even though we cancelled. I'm still trying to figure out how we can prove that one. I've been leery of this clinic from the beginning but more and more things about them are just adding to my mental health problems rather than helping them. We've already stopping going and my mental health has been slowly spiraling but we literally have no other place to go right now. We will figure out something to get me back in therapy, preferably someplace other than this clinic. WWYD about the crazy high bills that they won't back down one penny on?

[maize]

You can try appealing to your insurance company for them to pay.

[Ravin]

2 hours ago, sweet2ndchance said:

Would $400 per weekly 45 minute session with a licensed social worker with a therapy and counseling certificate who only does talk therapy (no CBT or psychoanalysis or diagnosing disorders or anything other than being a listening ear and offers the occasional platitude or book to read)sound reasonable to you? Or am I right in thinking that it sounds like they are milking insurance for all they are worth?

Sounds outrageous to me. My DD's therapist is similarly credentialed, does similar-ish therapy (I think there's a little more substance to it, and we only do biweekly 50-min sessions), and her rate for insurance is $175/session. Because my insurance bites, they won't bill them, so I pay a negotiated self-pay rate, get the detailed bills, and submit to insurance myself as out of network for...eventually...getting some reimbursement.

[Farrar]

I think this might be worth lawyering up over.

Can you ask around in your community and find out what they charge most people? Or just call them and pretend to be someone else or have someone else call and say they're interested in going in but don't have a plan that covers mental health so you can find out what they charge people in general instead of insurance.

[NorthwestMom]

43 minutes ago, sweet2ndchance said:

We are just now getting bill after bill for sessions dating back to last summer for $400 per session saying that we are liable for all of it because our insurance changed their policy last summer and will now only pay for 1 session per month. This is from the billing department not the insurance company. We haven't been able to get a hold of anyone useful from the insurance company yet. The itemized bills we are receiving show where insurance paid $400 for the first session every month and they are holding us liable for the other 3 per month.

Insurance had no problem paying for weekly therapy appointments in the larger city were we used to live but I'm not sure how much those other clinics were charging. We never had any billing problems from them. If we had known last year that a) they were charging this much and b) insurance wasn't paying for appointments then we would not have continued going despite the fact that I really need to be in therapy (I am diagnosed with PTSD, C-PTSD, severe anxiety, chronic depression, complex grief disorder and suspected Asperger's syndrome. These diagnoses were given in a psychiatrist's office 2 hours away) There is only this clinic charging $400 a session and one other clinic with a  6 - 12 month waiting list for a spot in our area. Everything else is 90 minutes to 2 hours away in the larger cities.

So far, the bills total almost $5,000. They will not pro-rate or sliding scale based on income for these bills. There are even a few dates on these bills that we are pretty sure we had to skip therapy that week because of scheduling conflicts and we always cancelled at least 3 days in advance but usually a week or more in advance so I know we weren't charged a "no show". They just billed insurance anyways even though we cancelled. I'm still trying to figure out how we can prove that one. I've been leery of this clinic from the beginning but more and more things about them are just adding to my mental health problems rather than helping them. We've already stopping going and my mental health has been slowly spiraling but we literally have no other place to go right now. We will figure out something to get me back in therapy, preferably someplace other than this clinic. WWYD about the crazy high bills that they won't back down one penny on?

This is illegal - it's insurance fraud. Insurance doesn't cover cancelled appointments ever. They only cover service provision.

Edited July 17, 2019 by NorthwestMom

[sweet2ndchance]

20 minutes ago, NorthwestMom said:

This is illegal - it's insurance fraud. Insurance doesn't cover cancelled appointments ever. They only cover service provision.

Yes I know but how does one prove it? All I had to do to cancel an appointment was call in at least 24 hours in advance to avoid a no show fee. I didn't have to submit anything in writing nor did they ever give me anything that confirmed I cancelled. It never occurred to me that I should have recorded the phone call just in case I suspected they would commit fraud, KWIM? I have no idea how I would prove we both cancelled and didn't show then they billed insurance anyways.

[sweet2ndchance]

55 minutes ago, Farrar said:

I think this might be worth lawyering up over.

Can you ask around in your community and find out what they charge most people? Or just call them and pretend to be someone else or have someone else call and say they're interested in going in but don't have a plan that covers mental health so you can find out what they charge people in general instead of insurance.

I want to lawyer up but I didn't want to jump the gun if this really was legitimately what therapy was charging these days. I paid out of pocket for marriage counselling with my ex-husband about 10 years ago and it was $150/session but it was in another state and 10+ years ago.

This social worker/therapist... we had to re-explain things over and over again even though it had only been 6 days since we last saw her and I really don't feel like we have moved forward with her at all, I just haven't had the backslide like I have had since we quit going when these billing issues surfaced. The day they mentioned the billing issues, we were going to ask to be transferred to a different, perhaps more credentialed, therapist in the clinic since my issues are many and complicated and our current therapist that I was assigned didn't seem up to the task. But instead that ended up being our last session when we found out how much they wanted us to pay which was about $1600 at the time.... we've gotten more bills in the 2 months since that last appointment bringing the total to almost $5000 as of the bill we received today. Sigh.

ETA: When I asked what they charge people who pay out of pocket because they don't have insurance that covers mental health they said they don't accept patients without mental health coverage and only billed insurance for their services. Now I know why....

Edited July 17, 2019 by sweet2ndchance

[sweet2ndchance]

Dh has a question now too..... On the billing statements we were given, the "date of service" are on all different days of the week. I have always only gone to this clinic on Thursdays. There is only one "date of service" for each week but very few of them are Thursdays. I (sweet2ndchance) think they just bill whatever day of the week they process the bills. Really odd that they don't do billing on the same day of the week every week or on the day that services were rendered but there are a lot of things like that around here that just make me shake my head. Dh (Mr. Sweet2ndchance) thinks there is something fishy with the dates being all over the place and very rarely on the actual date of service since they call it "date of service". Any thoughts on that?

[Joker]

I feel for you and I honestly don't know what the answer is. I've been battling a $500 bill for almost a year now. It is for two vaccines but the provider didn't bill it as such. I can show proof of them billing the same thing correctly before and after this date of service but no one cares. Everyone even admits it is for vaccines that are completely covered by my insurance. The insurance company has been zero help. Everyone seems to agree with me that it's wrong but the billing/coding department of the provider isn't changing it for some reason so I will probably end up paying it eventually. They have resubmitted the claim five flipping times now but always with the wrong code. I don't know how to make it right and it truly stinks that no one involved seems to use any common sense. 

[sweet2ndchance]

@Joker I have another bill from a pulmonologist that I have never seen. The bill is from 4 or 5 years ago. I've called the office and they say they have no record of me going there ever (because I have never been to a pulmonologist in my life!) so they said they would take care of it. But like clock work every time I go in to the hospital for anything, I have to sign a paper that says I have an outstanding bill that I'm not paying for today. I've talked to billing at the hospital, I've talked to the pulmonologist's office billing dept, I've never received a bill in the mail for it, everyone says don't worry about it we'll take care of it but every time I have to go into the hospital (which is every couple of months since that is where I have to go for my thyroid panels to be drawn) I have to sign that #*$% paper again.

Almost as frustrating as the time the insurance company tried to tell me *I* misspelled my daughter's name and that's why they weren't going to pay for her $24,000 hospital ICU stay when she had meningitis at 2 months old. Thankfully, I still had her insurance registration papers that showed I had spelled her very common name correctly and the hospital had her name on the bills correct but who ever typed the information from the registration papers into their computers had misspelled it. Just dealing with medical insurance feels like a full time job sometimes...

[Arcadia]

2 hours ago, sweet2ndchance said:

We are just now getting bill after bill for sessions dating back to last summer for $400 per session saying that we are liable for all of it because our insurance changed their policy last summer and will now only pay for 1 session per month. This is from the billing department not the insurance company. We haven't been able to get a hold of anyone useful from the insurance company yet. The itemized bills we are receiving show where insurance paid $400 for the first session every month and they are holding us liable for the other 3 per month.

 

If your insurance change their policy last summer and they only billed you for the other 3 session per month now, that is unprofessional. They should have informed you when the insurance did not pay for the second session after the policy change.  What does the statement for last summer from your insurance says?

I get a statement at least once a month from BCBS with details of what they were billed, what they pay and what is my patient responsibility. I get a bill at least once a month from my healthcare provider. It is tedious but easy to reconcile BCBS’s statements with my healthcare provider’s bills.

The bills from my healthcare provider has date of bill on the header portion and then line items with date of services in the main body of the bill. So I might get a bill with the date of bill being last Friday and the line items having dates of last Wednesday and Thursday for different procedures.

 

[sweet2ndchance]

16 minutes ago, Arcadia said:

 

If your insurance change their policy last summer and they only billed you for the other 3 session per month now, that is unprofessional. They should have informed you when the insurance did not pay for the second session after the policy change.  What does the statement for last summer from your insurance says?

I get a statement at least once a month from BCBS with details of what they were billed, what they pay and what is my patient responsibility. I get a bill at least once a month from my healthcare provider. It is tedious but easy to reconcile BCBS’s statements with my healthcare provider’s bills.

The bills from my healthcare provider has date of bill on the header portion and then line items with date of services in the main body of the bill. So I might get a bill with the date of bill being last Friday and the line items having dates of last Wednesday and Thursday for different procedures.

 

We don't get monthly statements, only notices when a bill has been rejected. I've asked about an itemized statement as we have always received those from other insurance that I've had but like I said, we haven't gotten a hold of anyone useful there yet. All we've been told is they only send out notices when a claim is rejected, they don't do statements.

We've received both the bills and the notice of non-payment for all these appointments within the last 2 months.

 

The bills just have a date of service, a description and a total on each line. We've had one person in billing tell us that that is the date of service and we must be just mis-remembering what day of the week we came in on and another one tell us that they don't necessarily process the bill on the same day that service is rendered. The latter would be fine except that makes it look like on some weeks they billed *before* services were rendered that week. It's all extremely sketchy...

Edited July 17, 2019 by sweet2ndchance

[QueenCat]

11 hours ago, sweet2ndchance said:

Insurance had no problem paying for weekly therapy appointments in the larger city were we used to live but I'm not sure how much those other clinics were charging. We never had any billing problems from them. If we had known last year that a) they were charging this much and b) insurance wasn't paying for appointments then we would not have continued going despite the fact that I really need to be in therapy (I am diagnosed with PTSD, C-PTSD, severe anxiety, chronic depression, complex grief disorder and suspected Asperger's syndrome. These diagnoses were given in a psychiatrist's office 2 hours away) There is only this clinic charging $400 a session and one other clinic with a  6 - 12 month waiting list for a spot in our area. Everything else is 90 minutes to 2 hours away in the larger cities.

 

 

Was it the same insurance company? Or different insurer with different policies? Or same insurer but the coverage changed. Coverage changes are typically published during open enrollment. 

[cjzimmer1]

I don't if mental health services work the same as medical services but can you request a copy of your records?  With medical records, it will list date of service and what was done.  If something like that is available for mental health, I think it would be easy to see for sure what days you were there and what days you weren't.  Of course if they office is fishy, they might not want to share that info with you but it's something you could look into.

[Arcadia]

9 hours ago, sweet2ndchance said:

We don't get monthly statements, only notices when a bill has been rejected. I've asked about an itemized statement as we have always received those from other insurance that I've had but like I said, we haven't gotten a hold of anyone useful there yet. All we've been told is they only send out notices when a claim is rejected, they don't do statements.

We've received both the bills and the notice of non-payment for all these appointments within the last 2 months.

 

If your insurance only send out notices when a claim is rejected, they should have sent you a notice last summer and not wait until two months ago.

Are the notice of non-payments from the therapist? Accounts are reconciled every quarter for business tax purposes as well as general accounting purposes. Either their accounts/billings are in a mess or they are shady for taking so long to bill you for last summer.

Is your name a common one? I would be worried about identity fraud for the pulmonologist bill. My insurance is under my husband’s employee health plan. The bill for DS13’s birth was messed up by the hospital and my husband just sat at the hospital’s billing office (in 2006) and called his insurance while sorting it out with the hospital’s billing dept.

[historically accurate]

We have 4 different therapists in my family. There are licensed social workers and marriage and family therapists. They range in price from $160 - $215 an hour (50ish minutes). One is out-of-network and we are billed $142.54 per session, which is medicare's reimbursement rate. $400 is outrageous. 

Can you get the records for the dates you weren't there? Ask for what they submitted to the insurance company. I would think they wouldn't want to hand that over to you if they are billing fraudulently. 

[sweet2ndchance]

1 hour ago, QueenCat said:

 

Was it the same insurance company? Or different insurer with different policies? Or same insurer but the coverage changed. Coverage changes are typically published during open enrollment. 

Same insurance. Same policy. The therapy clinic is the one stating the coverage changed. I can't get a straight answer from insurance whether their policy actually changed or not. I've search high and low for an online statement of benefits. The only one I can find is very vague. I've asked for a more specific statement of benefits but I'm just repeatedly referred to the online one. I cannot wait until we can afford better insurance. It should not be this hard to get a straight answer on what is covered and what is not.

[fairfarmhand]

2 minutes ago, sweet2ndchance said:

Same insurance. Same policy. The therapy clinic is the one stating the coverage changed. I can't get a straight answer from insurance whether their policy actually changed or not. I've search high and low for an online statement of benefits. The only one I can find is very vague. I've asked for a more specific statement of benefits but I'm just repeatedly referred to the online one. I cannot wait until we can afford better insurance. It should not be this hard to get a straight answer on what is covered and what is not.

Start asking for supervisors on the phone. Don’t be afraid to be direct and irritable. Not that you’re blasting the poor person on the phone but you do need to let them know exactly how disgusted you are with the run around. Threaten to call the news media if you don’t get some answers. Start talking about getting a lawyer. 

[sweet2ndchance]

1 hour ago, cjzimmer1 said:

I don't if mental health services work the same as medical services but can you request a copy of your records?  With medical records, it will list date of service and what was done.  If something like that is available for mental health, I think it would be easy to see for sure what days you were there and what days you weren't.  Of course if they office is fishy, they might not want to share that info with you but it's something you could look into.

I have asked and their dates match their billing. However, I have only ever gone on Thursdays. One thing we requested when we started with this clinic was to have all my appointments on one day of the week and if we couldn't make it or the therapist was out, we would just miss rather than reschedule for another day because one of my issues is having a hard time dealing with change, even little changes like going to therapy on Wednesday instead of Thursday. So I have no doubt that all my appointments were on Thursdays and I have record of when we had to miss because the only reason we missed an appointment (dh always goes with me to therapy for moral support) was because we had another appointment that could not be scheduled for a day other than Thursday. And yes, missing those therapy days messes with me too but with dh's health problems sometimes it just can't be helped. I can prove we were else where on those days but how can I proved that I did call to cancel if they maintain I was there and that's why they charged insurance?

[Pegasus]

I'm sure it varies by region but we were recently paying about $110 per session cash price for similar therapy.  I do think the first visit was higher, maybe $150?  I'm not sure what they would have billed insurance, more certainly.

[sweet2ndchance]

1 hour ago, Arcadia said:

 

If your insurance only send out notices when a claim is rejected, they should have sent you a notice last summer and not wait until two months ago.

Are the notice of non-payments from the therapist? Accounts are reconciled every quarter for business tax purposes as well as general accounting purposes. Either their accounts/billings are in a mess or they are shady for taking so long to bill you for last summer.

Is your name a common one? I would be worried about identity fraud for the pulmonologist bill. My insurance is under my husband’s employee health plan. The bill for DS13’s birth was messed up by the hospital and my husband just sat at the hospital’s billing office (in 2006) and called his insurance while sorting it out with the hospital’s billing dept.

No the notices of non-payment are from insurance, not the therapist clinic.

Yes, I was a child of the 70's and was often referred to as a child as "*first name* *last initial*" take from that what you will.

I've thought about possible identity theft but it has only ever been this one bill and no others. They say that everything is more relaxed in the country, I'm often accused of being "uptight" and "not from around here" because I insist on professionalism (which is another thing I've been told I need to work on in therapy is the ability to be flexible...). Apparently that relaxed attitude also extends to billing practices and accounting.

[maize]

12 hours ago, sweet2ndchance said:

Dh has a question now too..... On the billing statements we were given, the "date of service" are on all different days of the week. I have always only gone to this clinic on Thursdays. There is only one "date of service" for each week but very few of them are Thursdays. I (sweet2ndchance) think they just bill whatever day of the week they process the bills. Really odd that they don't do billing on the same day of the week every week or on the day that services were rendered but there are a lot of things like that around here that just make me shake my head. Dh (Mr. Sweet2ndchance) thinks there is something fishy with the dates being all over the place and very rarely on the actual date of service since they call it "date of service". Any thoughts on that?

Date of service should be the day you were actually there for service, never some other day.

Something fishy is definitely going on with this practice.

and yes $400 per session is high if you are not in a super crazy high cost of living area.

Is the therapist a contracted provider with your insurance or out of network?

[sweet2ndchance]

1 minute ago, maize said:

Date of service should be the day you were actually there for service, never some other day.

Something fishy is definitely going on with this practice.

and yes $400 per session is high if you are not in a super crazy high cost of living area.

Is the therapist a contracted provider with your insurance or out of network?

In-network

[maize]

You might look up medical billing advocates in your area and see if you can get a free consultation.

Tell your insurance company you suspect billing fraud--it is fraud to bill a date of service you were not there.

Download the pdf of your plan policy and see what it says about mental health service coverage. Past year brochures should be available.

[sweet2ndchance]

Thanks everyone for all of your support and experiences. I feel a little less crazy now for thinking that $400 a session was insanely high.

My dh has recently been diagnosed with a rare disease and we are working to get him the care he needs so that he might be able to get off the disability he has been on for two years now while we have been searching for a doctor that could figure out what was wrong with him. Fighting for his care and his medical needs normally takes all the strength and energy I have combined with my own problems that have nothing to do with his problems. We finally got him on a road to recovery within the last couple of months (he is being scheduled for brain surgery but it is a long slow process when you are low income) and then this lands in our laps at just about the same time.

I am often accused of being "uptight" and "not from around here" because I insist on professionalism when I deal with people like medical staff who I expect to have professionalism. I've been told more than once when insisting on professionalism that I need to "learn to be more flexible with (your) expectations". But I really feel like I am in the right on this one.

We just finished having to call in a patient advocate with my husband's care to get things on track and all the doctor's on the same page. He has a rare disease and is facing brain surgery to help alleviate the symptoms but there is no cure. But that advocate only works for the university system that dh is having to see his specialists at and they are 4 hours away. They don't know anyone in this area that can help with my medical/mental issues. I've already asked. Everyone we've asked around here about a patient advocate just looks at us like we've grown an extra head and just says "Oh honey you don't need that. Just go talk to billing and they will sort it out for you." completely ignoring that we've already tried talking to them like reasonable human beings.

I want to fight. I want to lawyer up and blast this clinic for their unethical at best, if not illegal, billing practices. Especially since they are only one of two options in the immediate area. But when your mental health isn't what it should be (I don't go just to talk about the stress we are under from dh's health issues and other day to day stuff. I have real mental health issues that I fight every day) it is hard to discern when you are being irrational and when you really are uncovering a hidden monster.

[TechWife]

13 hours ago, sweet2ndchance said:

Yes I know but how does one prove it? All I had to do to cancel an appointment was call in at least 24 hours in advance to avoid a no show fee. I didn't have to submit anything in writing nor did they ever give me anything that confirmed I cancelled. It never occurred to me that I should have recorded the phone call just in case I suspected they would commit fraud, KWIM? I have no idea how I would prove we both cancelled and didn't show then they billed insurance anyways.

 

Call the insurance company, tell them you suspect fraud and what dates. They will go back to the provider and have them prove that you were there. It is the provider's responsibility to prove that you were there. It is not your responsibility to prove that you weren't.

[TechWife]

I do think $400 per visit is extremely high for that level of care.

Have you called NAMI to ask them if there is someone who can help you advocate for you billing issues? They say to call and that they can provide referrals for advocacy organizations. You can also email them. Here's a link for you.

[itsheresomewhere]

400 is high for a high cost of living area.  That number would only make sense to me if it was your first visit and you need 1.5 hours appointment not a weekly established patient visit for 45 minutes.  Call your state’s insurance commissioner and your insurance company.  Tell them you suspect fraud and need help getting the answers to this.  For all you know this place has been reported but they need more evidence.  We had one near us that finally got enough to evidence and they were massively fined/prosecuted for the fraud. 

[lynn]

That is way high for a social worker.  Can you call and get a cash price?  I would make calls around town and see how much people charge.  Here was as low as $75 to $135 for licensed counselors.

[sweet2ndchance]

17 minutes ago, lynn said:

That is way high for a social worker.  Can you call and get a cash price?  I would make calls around town and see how much people charge.  Here was as low as $75 to $135 for licensed counselors.

I have asked them what the self pay cash price is for an appointment and they told me they don't accept self-pay patients so they don't have a cash price.

[AmandaVT]

Have you received explanation of benefits from your insurance company? I think a good first step is calling them to let them know what's going on. Mental health clinicians who contract with insurance companies agree (in their contract) to accept the insurance company's contracted rate. For instance, a social worker can bill $400 or $4000/hr all they want, but they will only get paid the contracted rate. They are NOT allowed to bill the client for the difference. Ever. 

They can bill no-show fees, but you would have needed to agree to that before they bill you. Each of the clinicians I work with has their own cancelation policy and generally the cancelation fee is $100. 

Also, if you have an insurance policy that is compliant with the ACA, it should cover mental health like any other Dr's appt. 

The wrong dates are also concerning. I would cross check against your records and let the insurance company know what's going on. In the meantime, don't pay the clinic anything. I am pretty sure the insurance company may audit the clinic if they think there is fraudulent activity going on. 

[EmseB]

I might also mention getting the state insurance commissioner involved in looking at the bills/billing practices, or if your state doesn't have one (I think all do?) the state AG's office. If they are committing insurance fraud, the insurance commissioner or AG would be the office to talk to, AFAIK.

You should have an itemized bill with a date of service for each visit (even if it wasn't billed the same day you were seen, the bill is for the appointment on X date), and it should be easy to get a record of appointments you actually kept from the therapist's office themselves.

[DawnM]

Whoah!  

No.  We pay $175-$225 per hour depending.  

[sweet2ndchance]

17 hours ago, AmandaVT said:

Have you received explanation of benefits from your insurance company? I think a good first step is calling them to let them know what's going on. Mental health clinicians who contract with insurance companies agree (in their contract) to accept the insurance company's contracted rate. For instance, a social worker can bill $400 or $4000/hr all they want, but they will only get paid the contracted rate. They are NOT allowed to bill the client for the difference. Ever. 

They can bill no-show fees, but you would have needed to agree to that before they bill you. Each of the clinicians I work with has their own cancelation policy and generally the cancelation fee is $100. 

Also, if you have an insurance policy that is compliant with the ACA, it should cover mental health like any other Dr's appt. 

The wrong dates are also concerning. I would cross check against your records and let the insurance company know what's going on. In the meantime, don't pay the clinic anything. I am pretty sure the insurance company may audit the clinic if they think there is fraudulent activity going on. 

Can you tell me more about the bolded? Where would I find more information about that? Does it still apply when Medicaid is a first or second payor? We've been forced to pay the difference on some of dh's medical bills. He has Medicaid as his only insurance due to being disabled and on disability. Is it different for Medicaid because of the low reimbursement rates? 

Yes, the no show fee is part of their contract you sign at the start of services but we've never no showed. We've always cancelled with in the appropriate amount of time to avoid a no show fee. Insurance will not pay no show fees and we can't afford the $100 no show fee. All these dates in question are not itemized as no show fees, they are billed just like the other dates that I know I attended.

What is ACA compliant? It was my understanding that these appointments were billed  and paid for like any other dr's appt but even doctor's appointments are limited to one per month unless it is for something acute. So for my thyroid things, we can only go into the actual doctor once per month and then everything else, like coordinating blood draws and such we do through email with the doctor since another appointment in the same month is out of the question for several reasons but one of them is the one non acute visit per month rule.

The plan right now is to do some major horn blowing when we have all our ducks in a row.

ETA: EOB is what they refer me to online and say they don't have a print version due to cost. Under mental health it just says that mental health is covered with a referral from PCP. It doesn't say how many appointments or if there are any limits, just that it needs a referral and we do have that referral and we keep it up to date. It needs to be renewed ever 6 months and we make sure that it is.

Edited July 18, 2019 by sweet2ndchance

[ILiveInFlipFlops]

Egads! Have you talked to anyone at the therapist's office about this, or have you just tried reaching the billing people? It's possible that the therapist's office may be using an outside billing service and has no idea the mess the billing people are creating. 

Who is your insurer? 

You likely won't get detailed benefits information online, but you should be able to get PDFs of your EOBs, and that's where you'll find the information about allowed amounts, contracted rates, etc. If you log into your online account with your insurance company, you should be able to find a section called something like Claims and Statements, or EOBs. If you go in there, you'll be able to see claims for each date of service your insurance has been billed for, and if you go into each individual claim, you can usually download the EOB associated with it. 

Here's an example of how in-network claims work for Blue Cross Blue Shield in New York. I work for a therapist (doing billing and insurance for the whole practice). If you don't have BCBS insurance, the visit fee is $150 per visit. If you do have BCBS insurance, we bill each claim at $150 per visit, but the BCBS contracted rate is capped at $95 per visit, so that is the maximum that we are allowed to charge. The client may have a $20 copay, so they'll pay $20 and BCBS will pay $75, but the total amount will never exceed $95. This is where the provider is never allowed to bill the client for more than the contracted rate (AKA balance billing).

We will bill out of network as well, and that's where allowed amounts and balance billing come in. Because we are not in-network providers with other insurance companies, we will bill those claims at $150 per visit, and the insurance company will tell us what they "allow"--basically, it means what they've decided is a reasonable and customary amount for that service in that area for the plan the client has. The allowed amounts via more expensive plans are higher, and with cheaper plans the allowed amounts are lower. The insurance company will pay whatever they pay based on their allowed amount, but in this case the clinicians ARE allowed to bill the balance to the client because they are not bound by any insurance contract. I can explain more about that, but it shouldn't matter if you're positive your therapist is in-network. 

If you want to PM me, I can try to help you sort some of this out. I'm happy to look at an EOB, if you can find and download one.

The bottom line is this: The absolute last thing any network provider wants is to be audited by the insurance company. If they're audited and inconsistencies are found, they face fines, interest fees, and possibly being de-credentialed by the insurer. If that happens, they'll likely lose most of their clients because they're no longer in-network. And it sounds like this practice has a LOT to hide. The first thing I would do is get an office manager or supervisor AT THE PRACTICE and find out who is doing their billing. If it's a third-party service, the practice manager needs to know what's going on and will likely step in. If it's in-house staff, that will be trickier. Can you reconstruct a list of dates you were in based on your records? Dates you canceled? I'd put together a list of bullet points detailing the inconsistencies you're seeing in the billing they're trying to push on you. Under no circumstances should you pay them ANY MONEY until you get this sorted to your satisfaction. 

I wouldn't report them to the insurance company just yet. That's your leverage in getting this straightened out. I would absolutely let them know you're willing to do it if they don't handle the problem.

Let me know if you have questions. This is what I do for a living. Some things may be different based on whatever state you're in, but the bottom lines should be pretty much the same. Here, legally, the therapist is responsible for the billing, even if they pay someone else to do it, so they'd better be on top of what's going on there. 

One last point: I'm willing to bet that your insurance company has not been paying anything like $400 per visit. That may be what they're billing the insurance company, but as noted above, if the providers are in-network, there's almost no chance that the contracted rate is $400 per visit. If your options are so limited that you want to continue at this practice regardless of all of this, you need to find out what the contracted rate is that insurance is paying them and tell the practice that you'll pay that amount for all the visits insurance didn't cover, minus a hefty discount for the financial stress and inconvenience of them dumping a year's worth of billing on you all at once. 

Edited July 19, 2019 by ILiveInFlipFlops
More info

[Carrie12345]

It’s almost always been $170, or close to it, in my semi-rural area.  Though I guess where we wnd up going isn’t a bit less rural.  That’s been with BCBS for most of the past decade.  However, almost every initial assessment session has been billed a few hundred dollars higher.