Insurance & Managed Care:
Frequently Asked Questions
How do I know if CPN’s doctors will be covered by my insurance?
As part of our commitment to service, we try to be available on all of the local insurance panels. Although there may be some exceptions, the odds are that we are on your panel. Feel free to find out by either checking your directory or Emailing the name of your insurance company, the type of policy, and your insurance ID number to office@swflpsychology.com
Will my insurance cover the services provided at CPN?
The terms of each insurance policy vary widely. Most policies do cover most of the healthcare services CPN provides. In order to serve you better, we will be happy to bill your insurance as a courtesy to you. Please note that this service does not release you from your responsibility to pay all fees. If you are insured under a preferred provider agreement, you pay the coinsurance and/or deductible amount(s) at the time services are rendered. If you are insured by Medicare, we will accept Medicare assignment. You pay the coinsurance amount and any deductible amount at the time of service. In many cases the cost of billing secondary insurance carriers exceeds the amount the carrier pays for services. Therefore, we cannot bill your secondary carrier, though we will provide you with a receipt with which you can request reimbursement.
What are the common exceptions?
Health insurance policies cover the diagnosis and treatment of illnesses such as depression, panic attacks, eating disorders, anxiety disorders, and substance abuse. Psychologists diagnose and treat these health issues, but we do many other things as well. Most policies do not cover the assessment of, or counseling for:- School-related problems including, in many cases, the diagnosis of attention deficits.
- Marital counseling or family counseling, to address conflicts within the marriage or the family.
- Services rendered in connection with the legal system.
Is there ever a difference between what the doctor recommends and what the insurance company says is “medically necessary”?
Since healthcare reform, the insurance industry has re-defined the term “medically necessary” to describe services that are covered by your individual policy. For example, pregnancy care is “not medically necessary” in a policy that excludes coverage for pregnancy .
How can I find out the terms of my policy?
Why is my insurance company now refusing to pay for services it had agreed to cover?
This happens with some frequency. When we get telephone or mail approval from insurance companies, they sometimes indicate this approval is “no guarantee of payment.” When this occurs you can write to your insurance company to request a review of its decision.
What is the relationship between the doctors and my insurance company?
Doctors are required to sign agreements with any panel on which they wish to serve. At CPN, we refuse to sign agreements that interfere with the quality of care. Other than these contracts, our interactions with your insurance company are made as a courtesy service to you. The relationships are between you and your doctor; and you and your insurance company.
Some Things To Know About Managed Care
Why do some people choose to pay directly for services rather than use their managed care policies?
Many of our patients choose to keep control over their healthcare in their own hands and their doctor's by foregoing the use of their managed health insurance policy. By opting to use your managed health insurance plan, you are electing to allow the terms of your policy to determine your access to various treatments, the amount of treatment you receive, your access to diagnostic procedures, and the level of confidentiality. Managed care companies are in the business of controlling how much money your insurance company pays out in claims. Some insurance companies have taken to sending authorization letters that suggest they will cover a service and/or a diagnosis but sometimes there is a catch or 'backdoor" by which they can change their mind after those services are rendered. All too often, they use that 'backdoor" to refuse payment. Sometimes insurance companies tell their insureds that a certain service or diagnosis is covered. But they don't always mention that this is only the case under certain conditions. For example, family therapy is often a covered service if it is being used for the treatment of a psychiatric illness but it is rarely a covered service when it is used for its more common purpose of treating problems in a marriage. Therefore, unless we receive an unequivocal letter of authorization, you will be responsible for payment of fees at the time services are rendered.
In managed care parlance, the term "not medically necessary" has come to mean "‘not covered by the policy that was purchased"'. The term "usual and customary fees" has come to mean the fees the insurance company deems reasonable, regardless of what the norm is in the community. Issues involving school, marital conflicts, personal growth and development disease prevention, and longstanding issues are among those that people often want to address but which are seldom covered under managed care. Health care coverage typically is limited to those sessions in which the focus is treating a diagnosed illness.
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