Can someone explain the reasoning behind this for me, please?
I am in the process of finding a new therapist. I’ve met with several for initial consultations. I had used my insurance for my previous therapist, and was told that as long as a session was coded as an “office visit” the charge would be subject to co-pay.
What I didn’t realize (and wouldn’t have known to ask) was that if my consultations with potential new therapists are coded as “psychiatric diagnostic interview” then they are subject to my deductible and co-insurance.
This I now discover after having met with several therapists. This is AWESOME. I now have several hundred dollars of responsibility. Which pisses me right OFF. I DID call to see if I was covered. I would have made different decisions if this one very, very important distinction had been pointed out to me! How in the bloody hell am I supposed to be an informed consumer if the information I’m given is not relevant? How am I supposed to know what the different codes are and what they mean? And anticipate when they will be used and when they won’t?
What I want to know is, what is the rationale behind writing a policy this way? The way it looks to me, there is a very strong disincentive to use your mental health benefits if your first meeting is going to cost you $300 even if every visit thereafter is only subject to a co-pay. Why would a policy be written this way? I switched jobs and policies and as sucky as my old insurance was, it didn’t have this issue.
BTW, it’s only the PhD’s that this is true for. The LMHPs all have me coded as an office visit.
Chalk this up to yet another very expensive learning opportunity on how insurance works. My old therapist was covered, I assumed an office visit is an office visit. Why would I think otherwise? When I go to see a new physician, there is no difference between my first visit with them and every visit thereafter.
God, you try to do what you’re supposed to do (verify coverage) and then you get hit with hundreds of dollars in bills because you are neither an insurance worker nor a mental health provider, don’t do that kind of work, and didn’t know to ask “what if my consultation is coded as a psychiatric diagnostic interview? Will that make is subject to my deductible?”
You can appeal their decision by telling your insurance company exactly what you have told us. You need to contact them to get the right address and then write a letter explaining that you called ahead to doctor’s offices and verified coverage but that they did not explain to you how they were going to code the visits and that if you had known you would not have followed the same course of action. They may still tell you to pay your deductible but at least you will have had the opportunity to argue your case.
In the future any time you have something big going on that you know about ahead of time, whether it is shopping for a therapist or going in for out patient surgery, call your doctor and get all of their billing codes for whatever you’ve got going on and then call your insurance company and explain to them exactly what you need and give them the billing codes the doctor gave you. You will be able to know ahead of time exactly what you will pay and you won’t be hit with unexplained bills unless something changes in the doctor’s billing or something unpredictable happens that needs to be taken care of in the same visit.
This was my first question. Also, did you read your plan materials? They usually tell you explicitly that your mental health benefits are subject to your deductible before the plan pays its share. When I was searching for a therapist for my family, I assumed the worst (and was correct). Truthfully, I’m surprised you were able to get your first therapist to code it as an office visit.
And, yes, there is a strong disincentive for people to use mental health benefits. In the recent past (and still sometimes today), even some doctors have thought of therapy as crap. Generally, the prevailing idea until the last two decades has been, “Get over yourself and snap out of it!”
Whether that’s a good idea or not doesn’t matter - it’s just the way it has been. To date, no insurance company is even required to include mental health as a part of its core benefits package. The Affordable Care Act is the first piece of legislation that requires that it be a part of a core benefits package. Of course, if that’s overturned, I guess that requirement will be as well.
You have answered your own question. Why would they want you to use a benefit that would cost them money, especially if it’s not something that’s going to kill you in the short term?
As to why your policy is written that way, you’d have to ask the HR person at your company. I can think of two possible reasons, either they specifically want to discourage “trying out” a bunch of providers because a diagnostic interview costs them a lot more money than a therapy session, or else the HR person simply said something like “we want office visits and therapy covered with a copay only”, so everthing else,whether it be ER visits, MRIs, medical equipment- including psych diagnostic interviews, gets lumped together and subject to deductable and coinsurance.
As for appeal- my company will make an exception if there is a “benefit misquote”- that is a subscriber claims they were told the wrong information, and a supervisor pulls the phone call and verifies it. There may be a difference between being told “if you see a psych it’s supject ot copay only” and “if the psych bills an office code it’s subject to copay only”. (As a side note, mental health providers don’t really bill office codes, therapy codes are different). If a member makes a big stink we may do an exception anyway regardless of what was said because like any other business if enough people are dissatisfied HR may well move to our competition the next year.
Yeah, this is what I will do in the future. I wish I had faith that this would always work. (I invision trying to call my insurance company and them telling me that they can’t tell me specifically what my policy covers even if I have the billing codes. I’ve just been thwarted so many times in the past trying to figure out what the fuck my policy covers and what services will cost me.)
But thanks, pbbth, that’s exactly the kind of strategy I wish I had known to employ in the first place.
I had my HR director call and verify my coverage for me when I started. BCBS told her that mental health was covered for a co-pay as long as it was coded as an office visit. Stupidly, I assumed that all my appointments would be a standard office visit, especially since I’d been to my old therapist several times under my new employer’s plan and there was never a problem. (And those sessions were not subject to my deductible.) Now I know there is this creature called “psychiatric diagnostic interview” and she’s a beast!
Of course, I know that my policy is always going to be written in such a way to make the most money for BCBS (she said resignedly), I’ve just never ever run into this problem before (and lemme tell you, I’ve used mental health benefits under many different policies).
I’m frustrated with the gotcha games and the loopholes. I guess I need to call and verify coverage for the waaaaam-bulance.
An upside is that I have several hundred dollars remaining in my FSA because I’m not going to therapy every week as I’d planned, so that relieves a bit of the frustration.
Yeah, I guess I knew that in my heart after I talked to BCBS last night. I was just hoping it would be something I could reasonably accept instead of “we really don’t want you to use this coverage”.
I wonder if I just started working with any one of these therapists instead of officially doing a consultation, if my first session would be coded as an office visit. Question for the therapists, I guess.
And, of course, from a theoretical standpoint managing my mental health has a big impact on my physical health, but insurance companies never see it that way.
I am a therapist who bills insurance, and this makes no sense to me. I always bill a 90801 (psychiatric diagnostic interview) for the first visit, and then 90806s (therapy, 45-50 minutes) after that. The benefits are NEVER different, other than getting paid about $10-20 more for the first session. I have never heard of the deductible applying to one and not the other. We don’t even have a code for “office visit.”
Ok, just spent an hour on the phone with BCBS. They state unequivocally that 90801 is not a “therapy visit” and therefore is subject to my deductible. 90806 “should” be subject to a co-pay. Only therapy is therapy and a psychiatric diagnostic interview is not therapy.
So sayeth BCBS.
(Don’t get me started on how “office visit”, “office services”, and “therapy visit” are three different things. Or why BCBS uses “therapy visit” to describe mental health coverage but not “office services” - because that’s medical! - even though “office services” is what my plan summary says. The rep at one point said, “M’am, I don’t know where you are seeing office services under mental health benefits.” From YOUR materials that I got from my employer!)
ETA: I’ve gotten one EOB so far. It shows $242.13 that I owe the provider. Considering I know one other provider I went to was told that I hadn’t met my deductible, that’s another… $100? There’s a third out there but BCBS says they haven’t gotten a claim from her, but she says she hasn’t heard from BCBS, so I’m just going to assume that’s another $200.
It kind of presumes that I now have to go back to see one of these therapists (even though I’m not thrilled with any of them) because otherwise I have to pay ANOTHER several hundred dollars to see if I like somebody else!
This is so crazy! It doesn’t make sense that they are saying the deductible applies for the intake but not the therapy. It also doesn’t make sense that they approved $242 for the same service we get $105 for in TN.
Tell HR you think diagnostic interviews should be covered like an office visit the next timethe policy renews? Unless your company bought a fully insured “boilerplate” policy like many small ones do it’s the company that decides what benefits they want for their employees. Insurance agents and salesman can make suggestions but ultimately the write (and charge appropriately) whatever benefits the company wants.
Part of the problem I think it the translation from medical to english. Listing a bunch of CPT codes, even just the most common ones, and whether they are subject to deductable or not isn’t going to meen a lot to the average person, so insurance companies try to “dumb down” what the benefits are and misunderstandings happen.
This… is really odd. My insurance covers both the diagnostic interview and the therapy equally. And it’s not cool that you feel stuck with your current therapist.
I feel your pain. Because my therapists have all been out of network (since in-network options suck), I have to submit claims for each visit, which means I pay the full cost up front and then ask them for some money back. My most recent claim was denied because I didn’t have pre-authorization… which, I did, I just didn’t realize it expired and I had to get it authorized again. Because even though we pay extra for mental health coverage, they will still only authorize 8 visits at a time. So now I have to submit an appeal for $1600 worth of therapy. And that totally leaves aside the $10,000 worth of TMS I am trying to get reimbursed for - at this point it has gone beyond the insurance company and we are appealing the state entity that can overrule the insurance company’s decision. That, at least, I knew to expect.
I’m pretty sure they make it such a massive pain in the ass in hopes we just give up.
This is the only thing that makes any sense to me, and it only makes a little. I have seen hundreds of mental health policies and NONE of them work the way that the OP has been told hers does. If that is the issue, it is a crazy way for the policy to be worded.
I hear you, but my insurance company, IMO, SHOULD know that a first session is commonly coded as a psychiatric diagnostic interview and they SHOULD have advised me that that code is subject to my deductible. Why else would I be calling to verify my coverage if not to be advised of that very type of thing? That’s not a misunderstanding, IMO, that’s being fucking mislead. They’re not on the hook for potentially a grand, I am, because I acted in good faith on the information I was given. That’s horseshit.
Yeah, my next step is to research how to appeal this. When I talked to BCBS I told them I want it in writing that 90801 is not considered a “therapy visit” and that 90806 is only subject to a co-pay. I may be shit out of luck, but if I have to contact the insurance commissioner in my state, I will.
And, like I said, I do feel stupid for assuming that my consultations would count as an office visit. I guess I should have checked in advance with the therapists I was meeting with. I just assumed since my earlier therapist was covered under this plan, and that I’d always had my therapy covered under prior insurance plans… I think that’s a reasonable assumption for a reasonable person to make. I’m angry because I feel like everything is a gotcha game (and not just insurance) and that it is near to impossible for the consumer to make good decisions, especially when they are not given all the information they need to make a decision. And when you TRY to get all the information you need you get bullshit run-around and are told “go and use the provider’s service, and we’ll tell you how much it’s going to cost afterwards”.
If that is the issue, it is a crazy way for the policy to be worded.