September 22, 2023 • 35 mins
Ever grappled with the intricacies of mental health insurance? Well, struggle no more as we bring Michelle Riley, an expert in mental health and insurance billing, to simplify it all for you. Michelle opens up our conversation by unraveling the complex world of health insurance for mental health care. She takes us on a journey through the types of mental health services covered and demystifies the workings of co-pays, deductibles, and premiums as they relate to mental health coverage.
Our discussion takes a deeper turn as we step into the realm of in-network and out-of-network providers. Michelle sheds light on the pros and cons, assuring us that sometimes, opting for out-of-network can be the best option for your mental health needs. Ever wondered how to verify if a provider is in-network or accepts a certain insurance? Michelle has got you covered on that too.
As we round up our enlightening chat, Michelle shares the secret to maximizing your mental health insurance benefits. From understanding your insurance tracker and saving your explanation of benefits (EOB) to utilizing the provider portal, she has you covered. She emphasizes the need to stay vigilant as insurance companies can sometimes make mistakes. Be sure to tune in for a detailed breakdown of how to not just navigate, but conquer the world of mental health insurance. Remember, your mental health journey should be about focusing on your wellbeing, not worrying about the financial side of things. We're here to help you make that a reality.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:01):
Welcome to the Kindermind podcast, where we're
devoted to opening upconversations and destigmatizing
mental health.
We'll bring you interviews withpractitioners in the field of
mental health, researchersuncovering new knowledge and
best practices for treatingmental health disorders, and
individuals sharing their mentalhealth journey.
All right, today we have thepleasure of talking with
(00:22):
Michelle Riley.
Michelle has been in the worldof mental health and insurance
and billing for a number ofyears, so I'm so excited to have
her as a guest on the show toreally break down all of the un
they're standing around usingyour mental health benefits
(00:44):
through your insurance, whatthat means, what that looks like
out of network in network, allof these things that you might
hear if you try to use yourinsurance benefits to cover
mental health therapy.
So Michelle's just going towalk us through and give us a
nice understanding of what thatlooks like, so that you're not
afraid to access those benefitsand that you are informed.
(01:06):
Thank you so much for joiningus today, michelle.
It's great to have you on theshow.
Speaker 2 (01:10):
Thank you, I'm happy to be here.
Speaker 1 (01:13):
Yes, and we are happy to have you here.
So to kick us off, can youexplain kind of the basic
concept of health insurance andwhy it's important for mental
health care?
Speaker 2 (01:26):
So health insurance was designed to protect us and
our families, to make sure thatwe don't get hit with high
health care bills.
It's very important to havehealth insurance for many
reasons.
You get access to more care,you get access to more
facilities, you get access tomore type of different
(01:46):
physicians and specialists, andthe out of pocket cost is not as
much as if you would be payingout of pocket with no insurance.
So it's very important.
Mental health, very importantfor mental health.
It's been quite a few years nowthat insurances have now
accepted mental health as one ofthe medical conditions where
(02:10):
they cover at the same amount ofcoverage as they would any
other type of medical conditions.
So mental health has came along way with insurance.
It's very, very good now.
Speaker 1 (02:26):
Awesome.
So then, what type of mentalhealth services are typically
covered by health insuranceplans?
Speaker 2 (02:32):
So right now.
So outpatient care, which couldmean individual therapy, family
therapy, marriage counseling,as well as group therapy.
That's actually really a newone that just started to get
covered by mental healthbenefits.
Very, very good, and beforethey would not cover group
(02:53):
therapy, and I'm very happy theyare.
Substance abuse Substance abusehas come a long way, so now
more clients can get help ifthey're dealing with a substance
abuse diagnosis.
We also have in IOP, which isintensive outpatient.
That is more of staying in anoffice for a longer amount of
(03:13):
time, included with seeing apsychiatrist getting access to a
lot of group therapy.
That is also being now coveredby insurance.
You have inpatient where youhave to stay.
If you feel that you're justoutpatient and group is not
working for you, you can goinpatient.
That is now covered.
(03:35):
Medications are covered,psychiatry is covered,
psychology is covered.
So they now have covered everysingle part of mental health.
Speaker 1 (03:46):
That is wonderful.
Definitely there's a huge need.
So I'm glad the insurancecompany finally got on board and
decided hey, we're going to dothis for our members, our
customers, our people that payus.
So that's really great to hear.
So now the convoluted parts.
At least for me who is not inthe world of insurance and I
(04:07):
admittedly struggle with my owninsurance and understanding all
the things Can you tell us howco-pays, deductibles and
premiums work in the context ofmental health and coverage?
Speaker 2 (04:20):
Sure.
So whenever you sign up for anytype of health insurance, you
receive a packet and inside thatpacket you have to look over
all the benefit types and allthe premium types that you would
want to sign up for.
So that is all differentamounts of premiums.
(04:41):
So you're able to review thatpacket Because in that packet
you also see something calleddeductibles, co-insurances,
co-payments at a pocket cost.
This is where it gets confusing.
So let me start by saying thehigher your premium, the less
you're going to have to pay outof pocket for services.
(05:01):
So that's actually a very bigkey to people that kind of don't
understand the lingo ofinsurance.
So if your premium, yourpremium, is what you're going to
pay a month for your insurance,the lower your premium.
I'm sorry.
The higher your premium, thelower your benefits would be.
So I'm going to give you anexample.
(05:23):
So we have something called adeductible.
A deductible is the mostconfusing, I can say, aspect of
insurances.
A deductible is an amount thatan insurance makes you
responsible for before they'regoing to pay any out-of-pocket
costs to your insurance.
So if you come into a doctor'soffice and you have a $2,000
(05:48):
deductible, that deductible isyour responsibility until it has
been met.
That means you would have topay into it to meet it.
So if you're seeing a doctorthat charges $200 and you
haven't met that deductible,that $200 is going to get
applied to your deductible,saying that you now have to pay
(06:11):
your doctor the $200out-of-pocket.
And it keeps going on and onand on like that until you reach
$2,000.
Now anything, any service thatyou've done, lab work, any type
of, for instance, radiology,x-rays, mris, cat scans, any
(06:32):
other doctor visits that allgoes into that deductible pool.
So it's just not for yourmental health.
It's everything in one.
So it's always good to keeptrack of your deductible.
Also, some plans the deductibleis not only an individual
deductible can actually breakdown in two.
(06:52):
So you have an individualdeductible and a family
deductible and whicheverdeductible is met first, that's
the deductible that they will.
Once it's met, they will goahead and start paying your
clinician, your doctor, yourtherapist, anybody that you're
seeing.
So where a lot of people getconfused with deductibles is
(07:15):
when they come into an office.
They think, oh well, I have adeductible but I also have
insurance and I have a copayment.
Copayment and coinsurance doesnot pick in until your
deductible is met.
So you have to meet thatdeductible.
That is the first line of thefence when you're coming into
(07:36):
insurance using your insurancein a doctor's office.
So you have to have met thatdeductible.
This is very important.
Once your deductible is met, wemove on to do you have a
copayment or do you have acoinsurance?
Okay, deductible is 100% met.
Now the insurance is saying youdon't have to pay 100% of the
(07:58):
visit because your deductible ismet.
But we are now applying acopayment or coinsurance, which
is a portion.
Coinsurance is a portion of thevisit and a copayment is in a
set amount that you're going topay for that visit.
Every visit.
That can range anywhere from $1to I see them as high right now
(08:18):
is about $80.
Coinsurance is a percentage.
That percentages Okay, you'reresponsible for 20% of what your
insurance allows.
It's very similar to acopayment is just a percentage.
So copayment is a number amount, a coinsurance is a percentage.
(08:39):
So it's good to know which oneyou're going to be responsible
for, because then that makes adifference when you're paying
your costs at the front desk ofany of your visits.
Speaker 1 (08:50):
Have you ever?
Is it ever a thing where youhave to pay a copayment and
coinsurance, or is it one or theother?
Speaker 2 (08:59):
No, it's going to be one or the other.
It can never be both.
So deductible is going to bethere, but copayment and
coinsurance will never betogether.
It's going to be one in one andthat will be in your benefit
package that you receive fromyour insurance company.
Once you pick the premiumYou'll be able to say okay, I
want to do a coinsurance, notclearly a coinsurance.
You're going to end up payingmore money than what you usually
(09:21):
pay.
With a copayment because you'repaying a percentage, and that's
where the premium that you payper month comes into play.
Again, the higher your premium,most likely you're going to
have a copayment and not acoinsurance, because coinsurance
change with every specialty andevery service.
A copayment usually won't.
(09:42):
So if you come for a visit youknow a 30 minute visit, say,
with therapy, a 45 minute yourco-payments are going to stay
the same throughout any timeframe.
A co-insurance is going tochange because the amount billed
to the insurance company isgoing to be higher.
So your percentage is going tobe higher because it's
(10:06):
percentage-wise Okay.
Speaker 1 (10:09):
That makes a lot of sense.
Then, if you do have aco-payment, no matter whether
you're doing a 30-minute therapysession or a 60-minute therapy
session, you're paying the sameamount of money for your
co-payment, exactly.
Speaker 2 (10:22):
The only thing that changes is the amount billed to
the insurance, but that hasnothing to do with the client
Co-insurance.
It will have something to dowith the client because the
higher the bill is, the morepercentage they have to pay.
Speaker 1 (10:35):
Okay, that makes a lot of sense.
Now I know I've kind of seenthis question floating around
out.
There Are providers who and Iguess this will kind of segue us
into a nice net conversationabout in-network and
out-of-network but are providerswho are in-network with an
insurance company required totake that co-pay from the client
(10:57):
?
Speaker 2 (10:58):
They are required by the insurance law we call it to
take the co-pay just becausethey signed a contract with the
insurance company for that rateand they're required to collect
it from the patient.
There are cases where apatient's not going to be able
to pay that, which then it hasto be working with the office
and we have to have something inwriting from the patient why
(11:20):
and we have to report it to theinsurance company it is required
Deductibles in-network, andco-payments and co-insurance are
required to be collected at alltimes from the clients.
Speaker 1 (11:31):
Roger, thanks so much for clearing that up.
Now, thinking about in-networkand out-of-network, that's
another place where I'vepersonally struggled.
I don't even know if I haveout-of-network benefits.
We have tricare military, soI'm not sure.
Maybe, maybe not.
Can you tell us a little bitabout what it means for a
(11:53):
provider to be in-network orout-of-network and what that
means in terms of are you stillable to see that person or not?
Speaker 2 (12:03):
In the sense of the provider.
We'll start there.
A provider that wants to bein-network is basically signing
a contract with a contract thatrate from each insurance company
.
That means that the insurancecompany is not going to pay the
provider more than what theinsurance contract is, no matter
how much of provider bills.
The bill can be sent for $1,000for a certain code, but in that
(12:26):
contract you're a contractthat's $75, and that's all
you're going to get.
Now, when you go out-of-networkfor providers, you're not abided
to any contract.
It's an open contract.
There's no negotiated rates.
They will pay what they thinkis best for the service, based
(12:46):
on what you pay.
With the physician charge youcan't charge outrageous amounts,
but they do pay a lot higher tothe providers if they were to
go out-of-network.
We'll go into a sense of whyout-of-network sometimes is best
.
It don't sound good by mesaying that the providers
probably get paid more and mostlikely get paid a lot more, but
(13:08):
there's a reason behind all ofthat Going into it for a client.
I like the fact that clientsget to choose if they want to go
in or out-of-network.
Going in-network and I'm justgoing to blurt this out so
everybody can understand is anin-network office is going to be
one a lot busier.
(13:29):
That means that the appointmenttimes are harder to get.
It's just very hard.
It's harder to get in-networkoffice than an out-of-network
office is where I'm getting that.
The care is a little bitdifferent because providers make
a little bit more money off ofout-of-network.
Their offices are going to benicer.
(13:50):
Well, supposedly this is howit's supposed to be Nice.
They can get in a lot quicker.
They can do any serviceout-of-network.
They're not contracted toanything.
That means they can provideanything they want, any
pamphlets they want.
Everything is covered by theinsurance company out-of-network
.
In-network you only can do thecodes they say you're allowed to
(14:11):
do.
That means that you don't getthe opportunity to the different
services that added network canprovide you.
Now the downfall of addednetwork is the deductibles are a
lot higher.
Added network.
Some plans don't have addednetwork.
Like you said, your tricaremaybe.
It doesn't have added network.
I can tell you tricare doesn'thave added network.
Speaker 1 (14:33):
Okay, good to know.
Speaker 2 (14:34):
Tricare has added network and their added network
is very good.
The deductibles are higher.
Added network which means thatoffices are allowed to collect
those deductibles up front.
If you go into an office thatmeans that you're going to have
to pay $300 out of pocket.
I mean I have seen addednetwork at $500 deductibles.
(14:59):
That's very low because thedeductible started 100 up.
But if you have a highdeductible $5,000, $10,000,
these deductibles can raise veryhigh added network.
But the provider once again,they're not contracted with the
insurance companies.
They can work with yourdeductible and work with
(15:19):
anything within them benefitsany way they like.
They can charge you.
They don't have to charge you.
They're not required to collectanything.
There's no such thing asco-payments with added network.
It's all co-insurances.
They don't have to charge younothing.
They can see you and work out apayment plan with you if they
(15:39):
want, because once the insurancedoes pay, it does pay more.
A lot of providers now add anetwork.
They waive a lot of thedeductibles and half of the
deductibles.
Does that make sense to you asa civilian understanding this in
and out of network?
(16:00):
Because I know it can be alittle confusing.
Speaker 1 (16:01):
It does.
It sounds like for in network,I know no matter what for
tricare at least, I'm not goingto get a bill.
If I did have a co-payment, Iknow that I'd pay my co-payment.
Insurance would take care ofthe rest.
Then it sounds like for out ofnetwork, it's all going to be
dependent on the provider andhow much my insurance is going
to pay that provider, and thenI'm going to be responsible for
(16:24):
the rest.
Speaker 2 (16:26):
Correct.
If the provider wants to chargeyou for the rest, they don't
have to.
When you're seeing an addednetwork provider, it is.
You have to ask all thequestions.
You have to ask okay, I havethis deductible, will I be
responsible for the wholedeductible?
Will I be responsible for theco-insurance, or do you work
that out with me?
Most providers that see clientsat a network, they
(16:47):
individualize financial planwith each client.
Another amazing thing forclients is you can go anywhere
in that state for at a networkAnywhere.
That means that you don't haveto go to just in network.
They have their providers andthis is the only places that you
(17:08):
can go to Add a network.
You can go anywhere you want.
You got to be within the statebecause the provider is a
license in that state, but youcan go anywhere you want.
You do not have to go to acertain provider because the
insurance said so.
Speaker 1 (17:24):
Okay, that makes a ton of sense.
How can individuals verifylet's say they don't want to do
the out of network, they'reworried about getting a bill or
having that financial liability?
How can clients verify if aspecific therapist is in network
or accepts their insurance?
Speaker 2 (17:44):
I always tell clients on the end of the billing is
just because you called theoffice to verify your benefits.
You should always check yourbenefits yourself because
they're different, usually onthe clients and then RN, they
all come together the same, butusually the members area.
They have more accurateinformation than we would do on
(18:04):
the provider.
Then First thing you should dois call your provider's office,
ask the questions Okay, if Ihave a deductible?
And my response is what holddeductible?
Are there payment plans?
Do you collect the wholecoinsurance amounts?
If I met my out of pocketamount, do you still collect
your coinsurance?
(18:24):
You just got down all theanswers Immediately after you
hang up, you call your insurancecompany.
You want to know, okay, what ismy deductible, how much have I
met so forward towards where myout of network deductible,
what's my coinsurance and whatis my out of pocket and how much
(18:44):
have I met so with that out ofpocket.
All of these factors are veryimportant when you think of your
finance issue.
If you have any issues withfinances to go out of network
because out of network can get alittle expensive Same thing in
network you want to ask the samequestions.
Just because you're deductible,you still want to know what's
(19:05):
met in network.
You still want to know what'smet to a degree, out of pocket.
You do want to also know if youhave a co-pay or coinsurance so
that you know when you get tothat doctor's office, you know
what you're going to pay.
So definitely a lot of peoplelike to go online and check the
benefits.
It's quick but it's notefficient because they don't
(19:26):
update your benefits every day.
You could have had a procedureyesterday that still hasn't been
reflected on your bill becausethe providers can.
They have up to 60 days to bill.
So it's always good to callyour insurance company and talk
to them and have somebody giveyou the benefits and give you a
reference number.
Speaker 1 (19:46):
Okay, that's really great advice.
I never even thought about thatbecause we, you know, with
technology where like, oh, okay,I can just log in and I can
just check this for myself.
But you're absolutely right, ifyou want that most updated
snapshot of your benefits and,you know, fill that piece of
mind of I had a person on thephone with a reference number
(20:09):
tell me this information, then,for any reason, should that
information turn out to be falseor inaccurate, you've got a leg
to stand on for.
You know, calling the insurancecompany and trying to get a
resolution.
Speaker 2 (20:22):
You're absolutely correct.
They have to honor it, andelectronic is one of the best
things that's ever created isour electronics.
But let me tell you how much wedepend on them and how much
they are wrong half the time.
So, something this important,you're going to want to speak to
somebody and get a referencenumber.
Speaker 1 (20:39):
Absolutely.
That's a really great point.
Thanks so much for sharing allthat.
Another question I hear a lotare their limitations or
restrictions on the number oftherapy sessions that a client
can have under their insuranceplan?
Speaker 2 (20:54):
So it's based on your insurance plan.
We came a long way withinsurances where up to even
three years ago they you wouldhave to get authorization and
then they'll only give you eightvisits and then you have to
call back and tell them yourlife story all over again and
where you're at in treatment oryour clinician have to do that,
(21:15):
especially for mental health,and then they'll give you
another eight visits and this iskind of keeps on going and
they'll cap you at a certainamount per year.
Now a law is passed wherethey're not supposed to do that
anymore.
So now you can be seen up tothree times a week, even four if
you have authorization formental health, and that includes
(21:36):
individual therapy, familytherapy, group therapy, now IOP.
That is on another level.
We're just talking aboutoutpatient.
You can be seen up to threetimes.
With that included medicationmanagement, that can be your
fourth visit.
You can be seen the whole week.
If you're you doing differentthings.
(21:56):
There's a new visit to youryear that does not exist anymore
.
The only thing that changesthis is if you are using an EAP,
which is an employee assistanceprogram.
That is where your employeroffers their employee assistance
program through a certain thirdparty insurance or part of, for
(22:19):
instance, your non-healthcare.
And sigma have it, and Etna nowhas it as well, where they'll
give you three visits for justthey'll pay.
Your employer will pay throughthe insurance, through visits,
but after that your CAF, thenyou have to use your benefits or
you have to call in and getrecertified again to see if you
(22:40):
can get some more visits.
So now EAP is the only thingdifferent, even your Medicaid
plans.
You have unlimited visits formental health now.
Speaker 1 (22:49):
That is phenomenal because I remember hearing back
before I was in network withanybody.
I remember hearing a lot offrustrations from the provider
side and the mental healthcommunity that it seemed really
restrictive for them to have toreally justify to the insurance
company like this person isstruggling with their mental
(23:11):
health, they really need thislevel of support and to try to
get those sessions covered.
And then from the client side,who's already dealing with this
overwhelming journey of mentalhealth and like the burdens that
come from just trying to getbetter and feel better, and now
they're having to really divulgeall of this extra information
to an insurance company to tryto get these sessions approved.
(23:33):
So that is so great to hearthat they're no longer limited
in the absence.
Speaker 2 (23:39):
No, no, even psychological testing is covered
without authorization, and evensubstance abuse.
That came a long way.
People were not getting helpbecause there was no coverage
for substance abuse Two, threeyears ago and now there's
coverage for it.
Now I had a network covered it,but they would not cover it in
network.
Medicare still doesn't coversubstance abuse.
They're the only ones that arestill lingering.
(24:00):
What substance abuse?
Other than that, every otherinsurance company will cover it.
Speaker 1 (24:05):
Okay, very good to know.
So, thinking about coverage andpayments and deductibles and
all of the things, can you helpunpack this mysterious word that
I know I hear a lot?
And I will immediately raise myhand and admit that I'm just as
guilty as probably a hundredpercent of our clients.
(24:26):
When I get this little thing inthe mail called an EOB, I don't
even open it most of the timeand it goes right in the trash.
Speaker 2 (24:35):
What is an?
Speaker 1 (24:36):
EOB or explanation of benefits.
Why should I not throw it inthe trash?
What does it all mean?
Speaker 2 (24:42):
Well, that is your tracker.
It's like your paste of whenyou work.
It's tracking everything.
It's tracking if yourdeductible has been met.
It's usually at the bottom ofthe EOB.
It's tracking what?
So let's start with.
It tracks the visit that youwere seeing.
Every visit that you wereseeing by a provider is.
They're going to send you anEOB every time or you're going
(25:03):
to get it electronically or inthe mail.
It's going to have that date.
It's going to have the providerthat you're seeing.
It's going to have the servicethat was done.
It's going to have what theprovider is going to charge you
or going to charge your card onfile.
It's going to have yourdeductible amount If it went
towards where you deductible orif it paid the provider directly
.
(25:24):
If it goes towards where thedeductible, then that's your
responsibility to pay thatprovider.
Or if you sign something sayingthat we can charge the card on
file, us billers will charge thecard on file for that
deductible.
It's going to let you know whatthey paid the provider, if they
paid the provider anything atthe bottom.
It's going to calculate howmuch you met towards where
you're at a pocket.
(25:44):
Let me tell you you're at apocket so important because once
you meet your out of pocket youhave no more co-pays for the
rest of the year.
You have no coinsurance for therest of the year.
Your appointments are coveredat 100%.
Now you want to track thatbecause providers can't track
that.
They don't Updated enough inthe system where we're going to
(26:04):
know all this patient met at apocket.
We don't know until you tell uswhat.
We get an EOB saying it waspaid at 100%.
Then sometimes we have torefund the patient.
So it's always good not tothrow that away because you'll
know exactly what your providerdid.
This is really big in emergencyrooms, not even outpatient,
(26:25):
because we all know theemergency room do charge a lot.
So I've had so many callsbefore working in emergency
medicine where like okay, thiswas double charge, this was
triple charge.
I didn't get this done becauseeverybody's moving so fast in
emergency room.
They were supposed to get itdone but now they're getting
charged for it.
So you want to read your EOBand you want to save them
(26:46):
because that is like yourencyclopedia of the insurance
world and also your medicalhistory of how much went towards
the word anything of yourinsurance.
So you never want to throw themaway ever.
Speaker 1 (27:00):
Okay, lesson learned.
Yeah, as soon as I heard it'slike a pay stub, I was like,
okay, this is an importantdocument.
Speaker 2 (27:07):
You know how you track your taxes on your pay
stub and you track how much yougot paid and how much they took.
That's exactly like a pay stuband a lot of people and they do
add a lot of, I can say, likeexcessive blue crosses.
It's like six pages.
The most important page is likeone page.
You can throw the rest away,but the page with everything on
it you're going to want to keep.
Speaker 1 (27:28):
Okay, good to know.
I will not throw another oneaway.
So how can someone like myselfor any of our listeners who are
wanting to use their healthinsurance for mental health
services?
How do they handle the billingand the claims?
Is there anything they need todo other than you know, just
(27:49):
calling their insurance companyto verify their benefits?
Is there anything they need todo on their end to use those
benefits?
Speaker 2 (27:56):
The most important thing is be very active in your
billing so you know you haveyour office, you have your front
desk staff that check benefits,you have your bill that it
bills out.
But it's always helpful whenclients check their benefits
themselves too to compare sothat there's no conflict when
(28:18):
the bill comes Like, oh, I gotcharges deductible I shouldn't
have.
And then you know us as billersare like well, this is what
your insurance said and they'relike well, my insurance said
something different.
So it's always good for themembers to make sure they know
what's going on and tounderstand that the insurances
do make mistakes.
They're not perfect and never,ever, just assuming the office
(28:40):
made a mistake.
I've been in this a long timeand I will never, ever not say
the insurances don't makemistakes.
They do, and when they makemistakes, they need to be held
accountable, and not thedoctor's office.
So definitely check yourbenefits before you're seen by
your provider.
You have access to everythingthat us billers have access to,
(29:02):
just in a different manner.
You have a provider, we have aprovider portal, you have a
member portal.
Everything in that providerportal matches whatever is in
that member's portal, so you cansee everything that we do at
all times.
That's something you should aclient should really, you know,
pay attention to.
They should really log on totheir provider portal at least
(29:23):
at the end of every month, justlike you go through your bills,
and you pay your bills at theend of every month or you have
certain dates set of time.
Make sure that you're goingthrough your claims, make sure
everything's correct, becausethen that also helps providers.
If the insurance makes amistake, then they can let us
know.
We can get it fixed.
Speaker 1 (29:39):
That's so great.
That answers my next questionwhat resources or tools are
available to help individualsreally understand and make the
most of their mental healthinsurance benefits?
And I think you nailed it righton the head the provider portal
.
So, if so, I'm assuming theprovider portal that's not
something that is or sorry, notprovider portal, member portal.
(30:01):
I'm assuming that's notsomething that's provided by the
physician or the therapist thatyou're seeing.
That's where your insuranceinformation lives, and the
people who own that portal arethe insurance companies.
So then you would just need togo to your insurance company's
website to log in and see thatinformation Correct.
Speaker 2 (30:22):
Yes, yes, yep.
You just have to log in, get ausername and a password and you
can see everything.
Any of every provider or everypharmacy builds.
Speaker 1 (30:31):
Awesome.
Okay, so I think we've gonethrough some pretty useful
information here.
I know I feel a little bitsmarter.
I would still probably call youif I got a little stuck in
navigating my insurance.
It's always helpful to have afriend who really understands it
and has been doing it for avery long time.
(30:51):
But in terms of utilizinginsurance to cover mental health
, I think the key takeaways wehave are you can do it.
You can choose whether you'regoing to look for an in-network
person and know exactly what isgoing to be charged and your
co-pay and your deductible, oryou can go out of network, where
it's more of a relationship andagreement between you and the
(31:12):
provider.
The insurance company doesn'treally get involved
contractually with the provider.
Really making sure you areadvocating for yourself and
aware of your own insurancebenefits so that there's less
likelihood of mistakes, and alsopartner in with your provider
and their billing office to stayup to date with changes that
(31:33):
are going on with your insurance, in case you are entitled to a
refund or something wasn'tsubmitted or the insurance
company made a mistake.
Really just knowing that andknowing that everyone is human.
It's not always the provider'sfault, it's not always the
insurance's fault.
I think we've really unpacked alot.
Explanation of benefits veryimportant piece of paper.
(31:56):
You want to keep that for yourrecord purposes.
Thinking of all that we'vetalked through, do you have any
tips or additional advice forlisteners who are currently
using their health insurance formental health care or
considering on doing that?
Speaker 2 (32:11):
Yes, I do.
First thing is know what you'resigning up for.
Know what benefit plan you'resigning up for, when your job or
you're on the marketplace.
Really understand.
If you don't understand, go toa friend that understands it.
Call the insurance company andhave them explain it to you.
I'm pretty sure there are alsopeople selling the insurance so
(32:34):
you can call them.
Understand what you're signingup for, because once you sign up
for it you can't go backwardsfor many, many months.
You're stuck with thisinsurance plan.
Know what you're signing up for.
I've even had my own familymember sign up for something and
I'm like why didn't you come tome first?
Now you signed up for the worstplan on earth and you're upset
(32:58):
because you're getting tons ofbills because you're not paying
any premium.
That means that on the back endyou're going to get charged for
everything.
Know what you're signing up for.
Make sure you know yourbenefits once you do.
Make sure you know what kind ofclinician that you're meeting
with, what kind of doctor you'remeeting with what, how the
(33:18):
whole billing process works.
Don't never be afraid to callthe office and ask to speak to
the billing office.
They should really be availableto you at least within 24 hours
of your call.
Ask questions.
Don't be afraid to ask anybilling questions to the
insurance company as well asyour provider's office.
Everybody should be there tohelp you.
Speaker 1 (33:39):
That's such a great call out and I can speak for all
of our team here at Kindermineand Michelle, who is our billing
and insurance guru.
We and she are always happy tobe here and answer your
questions and explain theinformation that we've received
when we checked your benefits.
(34:00):
But again, super important thatyou also reach out to your
insurance, verify that that'salso what you're hearing from
your insurance, so thateveryone's on the same page.
But absolutely that issomething that we value at
Kindermine is being here tosupport clients, making it
possible to use your insurance,so that you're not having to be
(34:24):
the one to figure that out andreally support clients on that
insurance billing in.
So then, all you really have tofocus on is therapy and your
mental health journey.
That is correct.
Well, thank you so much forjoining us today, michelle.
It was so great to see you andtalk to you and go through all
of these questions that I knowwe're super helpful for folks to
(34:46):
get the answers to.
Speaker 2 (34:47):
Yes, thank you, thank you for having me, absolutely.
Speaker 1 (34:54):
The Kindermine podcast is produced by Dr
Elizabeth Barlow, edited byMarco.
Antonio with music by PaxMinerva.
Thanks,
Welcome to the Kindermind podcast, where we're
devoted to opening upconversations and destigmatizing
mental health.
We'll bring you interviews withpractitioners in the field of
mental health, researchersuncovering new knowledge and
best practices for treatingmental health disorders, and
individuals sharing their mentalhealth journey.
All right, today we have thepleasure of talking with
(00:22):
Michelle Riley.
Michelle has been in the worldof mental health and insurance
and billing for a number ofyears, so I'm so excited to have
her as a guest on the show toreally break down all of the un
they're standing around usingyour mental health benefits
(00:44):
through your insurance, whatthat means, what that looks like
out of network in network, allof these things that you might
hear if you try to use yourinsurance benefits to cover
mental health therapy.
So Michelle's just going towalk us through and give us a
nice understanding of what thatlooks like, so that you're not
afraid to access those benefitsand that you are informed.
(01:06):
Thank you so much for joiningus today, michelle.
It's great to have you on theshow.
Speaker 2 (01:10):
Thank you, I'm happy to be here.
Speaker 1 (01:13):
Yes, and we are happy to have you here.
So to kick us off, can youexplain kind of the basic
concept of health insurance andwhy it's important for mental
health care?
Speaker 2 (01:26):
So health insurance was designed to protect us and
our families, to make sure thatwe don't get hit with high
health care bills.
It's very important to havehealth insurance for many
reasons.
You get access to more care,you get access to more
facilities, you get access tomore type of different
(01:46):
physicians and specialists, andthe out of pocket cost is not as
much as if you would be payingout of pocket with no insurance.
So it's very important.
Mental health, very importantfor mental health.
It's been quite a few years nowthat insurances have now
accepted mental health as one ofthe medical conditions where
(02:10):
they cover at the same amount ofcoverage as they would any
other type of medical conditions.
So mental health has came along way with insurance.
It's very, very good now.
Speaker 1 (02:26):
Awesome.
So then, what type of mentalhealth services are typically
covered by health insuranceplans?
Speaker 2 (02:32):
So right now.
So outpatient care, which couldmean individual therapy, family
therapy, marriage counseling,as well as group therapy.
That's actually really a newone that just started to get
covered by mental healthbenefits.
Very, very good, and beforethey would not cover group
(02:53):
therapy, and I'm very happy theyare.
Substance abuse Substance abusehas come a long way, so now
more clients can get help ifthey're dealing with a substance
abuse diagnosis.
We also have in IOP, which isintensive outpatient.
That is more of staying in anoffice for a longer amount of
(03:13):
time, included with seeing apsychiatrist getting access to a
lot of group therapy.
That is also being now coveredby insurance.
You have inpatient where youhave to stay.
If you feel that you're justoutpatient and group is not
working for you, you can goinpatient.
That is now covered.
(03:35):
Medications are covered,psychiatry is covered,
psychology is covered.
So they now have covered everysingle part of mental health.
Speaker 1 (03:46):
That is wonderful.
Definitely there's a huge need.
So I'm glad the insurancecompany finally got on board and
decided hey, we're going to dothis for our members, our
customers, our people that payus.
So that's really great to hear.
So now the convoluted parts.
At least for me who is not inthe world of insurance and I
(04:07):
admittedly struggle with my owninsurance and understanding all
the things Can you tell us howco-pays, deductibles and
premiums work in the context ofmental health and coverage?
Speaker 2 (04:20):
Sure.
So whenever you sign up for anytype of health insurance, you
receive a packet and inside thatpacket you have to look over
all the benefit types and allthe premium types that you would
want to sign up for.
So that is all differentamounts of premiums.
(04:41):
So you're able to review thatpacket Because in that packet
you also see something calleddeductibles, co-insurances,
co-payments at a pocket cost.
This is where it gets confusing.
So let me start by saying thehigher your premium, the less
you're going to have to pay outof pocket for services.
(05:01):
So that's actually a very bigkey to people that kind of don't
understand the lingo ofinsurance.
So if your premium, yourpremium, is what you're going to
pay a month for your insurance,the lower your premium.
I'm sorry.
The higher your premium, thelower your benefits would be.
So I'm going to give you anexample.
(05:23):
So we have something called adeductible.
A deductible is the mostconfusing, I can say, aspect of
insurances.
A deductible is an amount thatan insurance makes you
responsible for before they'regoing to pay any out-of-pocket
costs to your insurance.
So if you come into a doctor'soffice and you have a $2,000
(05:48):
deductible, that deductible isyour responsibility until it has
been met.
That means you would have topay into it to meet it.
So if you're seeing a doctorthat charges $200 and you
haven't met that deductible,that $200 is going to get
applied to your deductible,saying that you now have to pay
(06:11):
your doctor the $200out-of-pocket.
And it keeps going on and onand on like that until you reach
$2,000.
Now anything, any service thatyou've done, lab work, any type
of, for instance, radiology,x-rays, mris, cat scans, any
(06:32):
other doctor visits that allgoes into that deductible pool.
So it's just not for yourmental health.
It's everything in one.
So it's always good to keeptrack of your deductible.
Also, some plans the deductibleis not only an individual
deductible can actually breakdown in two.
(06:52):
So you have an individualdeductible and a family
deductible and whicheverdeductible is met first, that's
the deductible that they will.
Once it's met, they will goahead and start paying your
clinician, your doctor, yourtherapist, anybody that you're
seeing.
So where a lot of people getconfused with deductibles is
(07:15):
when they come into an office.
They think, oh well, I have adeductible but I also have
insurance and I have a copayment.
Copayment and coinsurance doesnot pick in until your
deductible is met.
So you have to meet thatdeductible.
That is the first line of thefence when you're coming into
(07:36):
insurance using your insurancein a doctor's office.
So you have to have met thatdeductible.
This is very important.
Once your deductible is met, wemove on to do you have a
copayment or do you have acoinsurance?
Okay, deductible is 100% met.
Now the insurance is saying youdon't have to pay 100% of the
(07:58):
visit because your deductible ismet.
But we are now applying acopayment or coinsurance, which
is a portion.
Coinsurance is a portion of thevisit and a copayment is in a
set amount that you're going topay for that visit.
Every visit.
That can range anywhere from $1to I see them as high right now
(08:18):
is about $80.
Coinsurance is a percentage.
That percentages Okay, you'reresponsible for 20% of what your
insurance allows.
It's very similar to acopayment is just a percentage.
So copayment is a number amount, a coinsurance is a percentage.
(08:39):
So it's good to know which oneyou're going to be responsible
for, because then that makes adifference when you're paying
your costs at the front desk ofany of your visits.
Speaker 1 (08:50):
Have you ever?
Is it ever a thing where youhave to pay a copayment and
coinsurance, or is it one or theother?
Speaker 2 (08:59):
No, it's going to be one or the other.
It can never be both.
So deductible is going to bethere, but copayment and
coinsurance will never betogether.
It's going to be one in one andthat will be in your benefit
package that you receive fromyour insurance company.
Once you pick the premiumYou'll be able to say okay, I
want to do a coinsurance, notclearly a coinsurance.
You're going to end up payingmore money than what you usually
(09:21):
pay.
With a copayment because you'repaying a percentage, and that's
where the premium that you payper month comes into play.
Again, the higher your premium,most likely you're going to
have a copayment and not acoinsurance, because coinsurance
change with every specialty andevery service.
A copayment usually won't.
(09:42):
So if you come for a visit youknow a 30 minute visit, say,
with therapy, a 45 minute yourco-payments are going to stay
the same throughout any timeframe.
A co-insurance is going tochange because the amount billed
to the insurance company isgoing to be higher.
So your percentage is going tobe higher because it's
(10:06):
percentage-wise Okay.
Speaker 1 (10:09):
That makes a lot of sense.
Then, if you do have aco-payment, no matter whether
you're doing a 30-minute therapysession or a 60-minute therapy
session, you're paying the sameamount of money for your
co-payment, exactly.
Speaker 2 (10:22):
The only thing that changes is the amount billed to
the insurance, but that hasnothing to do with the client
Co-insurance.
It will have something to dowith the client because the
higher the bill is, the morepercentage they have to pay.
Speaker 1 (10:35):
Okay, that makes a lot of sense.
Now I know I've kind of seenthis question floating around
out.
There Are providers who and Iguess this will kind of segue us
into a nice net conversationabout in-network and
out-of-network but are providerswho are in-network with an
insurance company required totake that co-pay from the client
(10:57):
?
Speaker 2 (10:58):
They are required by the insurance law we call it to
take the co-pay just becausethey signed a contract with the
insurance company for that rateand they're required to collect
it from the patient.
There are cases where apatient's not going to be able
to pay that, which then it hasto be working with the office
and we have to have something inwriting from the patient why
(11:20):
and we have to report it to theinsurance company it is required
Deductibles in-network, andco-payments and co-insurance are
required to be collected at alltimes from the clients.
Speaker 1 (11:31):
Roger, thanks so much for clearing that up.
Now, thinking about in-networkand out-of-network, that's
another place where I'vepersonally struggled.
I don't even know if I haveout-of-network benefits.
We have tricare military, soI'm not sure.
Maybe, maybe not.
Can you tell us a little bitabout what it means for a
(11:53):
provider to be in-network orout-of-network and what that
means in terms of are you stillable to see that person or not?
Speaker 2 (12:03):
In the sense of the provider.
We'll start there.
A provider that wants to bein-network is basically signing
a contract with a contract thatrate from each insurance company
.
That means that the insurancecompany is not going to pay the
provider more than what theinsurance contract is, no matter
how much of provider bills.
The bill can be sent for $1,000for a certain code, but in that
(12:26):
contract you're a contractthat's $75, and that's all
you're going to get.
Now, when you go out-of-networkfor providers, you're not abided
to any contract.
It's an open contract.
There's no negotiated rates.
They will pay what they thinkis best for the service, based
(12:46):
on what you pay.
With the physician charge youcan't charge outrageous amounts,
but they do pay a lot higher tothe providers if they were to
go out-of-network.
We'll go into a sense of whyout-of-network sometimes is best
.
It don't sound good by mesaying that the providers
probably get paid more and mostlikely get paid a lot more, but
(13:08):
there's a reason behind all ofthat Going into it for a client.
I like the fact that clientsget to choose if they want to go
in or out-of-network.
Going in-network and I'm justgoing to blurt this out so
everybody can understand is anin-network office is going to be
one a lot busier.
(13:29):
That means that the appointmenttimes are harder to get.
It's just very hard.
It's harder to get in-networkoffice than an out-of-network
office is where I'm getting that.
The care is a little bitdifferent because providers make
a little bit more money off ofout-of-network.
Their offices are going to benicer.
(13:50):
Well, supposedly this is howit's supposed to be Nice.
They can get in a lot quicker.
They can do any serviceout-of-network.
They're not contracted toanything.
That means they can provideanything they want, any
pamphlets they want.
Everything is covered by theinsurance company out-of-network
.
In-network you only can do thecodes they say you're allowed to
(14:11):
do.
That means that you don't getthe opportunity to the different
services that added network canprovide you.
Now the downfall of addednetwork is the deductibles are a
lot higher.
Added network.
Some plans don't have addednetwork.
Like you said, your tricaremaybe.
It doesn't have added network.
I can tell you tricare doesn'thave added network.
Speaker 1 (14:33):
Okay, good to know.
Speaker 2 (14:34):
Tricare has added network and their added network
is very good.
The deductibles are higher.
Added network which means thatoffices are allowed to collect
those deductibles up front.
If you go into an office thatmeans that you're going to have
to pay $300 out of pocket.
I mean I have seen addednetwork at $500 deductibles.
(14:59):
That's very low because thedeductible started 100 up.
But if you have a highdeductible $5,000, $10,000,
these deductibles can raise veryhigh added network.
But the provider once again,they're not contracted with the
insurance companies.
They can work with yourdeductible and work with
(15:19):
anything within them benefitsany way they like.
They can charge you.
They don't have to charge you.
They're not required to collectanything.
There's no such thing asco-payments with added network.
It's all co-insurances.
They don't have to charge younothing.
They can see you and work out apayment plan with you if they
(15:39):
want, because once the insurancedoes pay, it does pay more.
A lot of providers now add anetwork.
They waive a lot of thedeductibles and half of the
deductibles.
Does that make sense to you asa civilian understanding this in
and out of network?
(16:00):
Because I know it can be alittle confusing.
Speaker 1 (16:01):
It does.
It sounds like for in network,I know no matter what for
tricare at least, I'm not goingto get a bill.
If I did have a co-payment, Iknow that I'd pay my co-payment.
Insurance would take care ofthe rest.
Then it sounds like for out ofnetwork, it's all going to be
dependent on the provider andhow much my insurance is going
to pay that provider, and thenI'm going to be responsible for
(16:24):
the rest.
Speaker 2 (16:26):
Correct.
If the provider wants to chargeyou for the rest, they don't
have to.
When you're seeing an addednetwork provider, it is.
You have to ask all thequestions.
You have to ask okay, I havethis deductible, will I be
responsible for the wholedeductible?
Will I be responsible for theco-insurance, or do you work
that out with me?
Most providers that see clientsat a network, they
(16:47):
individualize financial planwith each client.
Another amazing thing forclients is you can go anywhere
in that state for at a networkAnywhere.
That means that you don't haveto go to just in network.
They have their providers andthis is the only places that you
(17:08):
can go to Add a network.
You can go anywhere you want.
You got to be within the statebecause the provider is a
license in that state, but youcan go anywhere you want.
You do not have to go to acertain provider because the
insurance said so.
Speaker 1 (17:24):
Okay, that makes a ton of sense.
How can individuals verifylet's say they don't want to do
the out of network, they'reworried about getting a bill or
having that financial liability?
How can clients verify if aspecific therapist is in network
or accepts their insurance?
Speaker 2 (17:44):
I always tell clients on the end of the billing is
just because you called theoffice to verify your benefits.
You should always check yourbenefits yourself because
they're different, usually onthe clients and then RN, they
all come together the same, butusually the members area.
They have more accurateinformation than we would do on
(18:04):
the provider.
Then First thing you should dois call your provider's office,
ask the questions Okay, if Ihave a deductible?
And my response is what holddeductible?
Are there payment plans?
Do you collect the wholecoinsurance amounts?
If I met my out of pocketamount, do you still collect
your coinsurance?
(18:24):
You just got down all theanswers Immediately after you
hang up, you call your insurancecompany.
You want to know, okay, what ismy deductible, how much have I
met so forward towards where myout of network deductible,
what's my coinsurance and whatis my out of pocket and how much
(18:44):
have I met so with that out ofpocket.
All of these factors are veryimportant when you think of your
finance issue.
If you have any issues withfinances to go out of network
because out of network can get alittle expensive Same thing in
network you want to ask the samequestions.
Just because you're deductible,you still want to know what's
(19:05):
met in network.
You still want to know what'smet to a degree, out of pocket.
You do want to also know if youhave a co-pay or coinsurance so
that you know when you get tothat doctor's office, you know
what you're going to pay.
So definitely a lot of peoplelike to go online and check the
benefits.
It's quick but it's notefficient because they don't
(19:26):
update your benefits every day.
You could have had a procedureyesterday that still hasn't been
reflected on your bill becausethe providers can.
They have up to 60 days to bill.
So it's always good to callyour insurance company and talk
to them and have somebody giveyou the benefits and give you a
reference number.
Speaker 1 (19:46):
Okay, that's really great advice.
I never even thought about thatbecause we, you know, with
technology where like, oh, okay,I can just log in and I can
just check this for myself.
But you're absolutely right, ifyou want that most updated
snapshot of your benefits and,you know, fill that piece of
mind of I had a person on thephone with a reference number
(20:09):
tell me this information, then,for any reason, should that
information turn out to be falseor inaccurate, you've got a leg
to stand on for.
You know, calling the insurancecompany and trying to get a
resolution.
Speaker 2 (20:22):
You're absolutely correct.
They have to honor it, andelectronic is one of the best
things that's ever created isour electronics.
But let me tell you how much wedepend on them and how much
they are wrong half the time.
So, something this important,you're going to want to speak to
somebody and get a referencenumber.
Speaker 1 (20:39):
Absolutely.
That's a really great point.
Thanks so much for sharing allthat.
Another question I hear a lotare their limitations or
restrictions on the number oftherapy sessions that a client
can have under their insuranceplan?
Speaker 2 (20:54):
So it's based on your insurance plan.
We came a long way withinsurances where up to even
three years ago they you wouldhave to get authorization and
then they'll only give you eightvisits and then you have to
call back and tell them yourlife story all over again and
where you're at in treatment oryour clinician have to do that,
(21:15):
especially for mental health,and then they'll give you
another eight visits and this iskind of keeps on going and
they'll cap you at a certainamount per year.
Now a law is passed wherethey're not supposed to do that
anymore.
So now you can be seen up tothree times a week, even four if
you have authorization formental health, and that includes
(21:36):
individual therapy, familytherapy, group therapy, now IOP.
That is on another level.
We're just talking aboutoutpatient.
You can be seen up to threetimes.
With that included medicationmanagement, that can be your
fourth visit.
You can be seen the whole week.
If you're you doing differentthings.
(21:56):
There's a new visit to youryear that does not exist anymore
.
The only thing that changesthis is if you are using an EAP,
which is an employee assistanceprogram.
That is where your employeroffers their employee assistance
program through a certain thirdparty insurance or part of, for
(22:19):
instance, your non-healthcare.
And sigma have it, and Etna nowhas it as well, where they'll
give you three visits for justthey'll pay.
Your employer will pay throughthe insurance, through visits,
but after that your CAF, thenyou have to use your benefits or
you have to call in and getrecertified again to see if you
(22:40):
can get some more visits.
So now EAP is the only thingdifferent, even your Medicaid
plans.
You have unlimited visits formental health now.
Speaker 1 (22:49):
That is phenomenal because I remember hearing back
before I was in network withanybody.
I remember hearing a lot offrustrations from the provider
side and the mental healthcommunity that it seemed really
restrictive for them to have toreally justify to the insurance
company like this person isstruggling with their mental
(23:11):
health, they really need thislevel of support and to try to
get those sessions covered.
And then from the client side,who's already dealing with this
overwhelming journey of mentalhealth and like the burdens that
come from just trying to getbetter and feel better, and now
they're having to really divulgeall of this extra information
to an insurance company to tryto get these sessions approved.
(23:33):
So that is so great to hearthat they're no longer limited
in the absence.
Speaker 2 (23:39):
No, no, even psychological testing is covered
without authorization, and evensubstance abuse.
That came a long way.
People were not getting helpbecause there was no coverage
for substance abuse Two, threeyears ago and now there's
coverage for it.
Now I had a network covered it,but they would not cover it in
network.
Medicare still doesn't coversubstance abuse.
They're the only ones that arestill lingering.
(24:00):
What substance abuse?
Other than that, every otherinsurance company will cover it.
Speaker 1 (24:05):
Okay, very good to know.
So, thinking about coverage andpayments and deductibles and
all of the things, can you helpunpack this mysterious word that
I know I hear a lot?
And I will immediately raise myhand and admit that I'm just as
guilty as probably a hundredpercent of our clients.
(24:26):
When I get this little thing inthe mail called an EOB, I don't
even open it most of the timeand it goes right in the trash.
Speaker 2 (24:35):
What is an?
Speaker 1 (24:36):
EOB or explanation of benefits.
Why should I not throw it inthe trash?
What does it all mean?
Speaker 2 (24:42):
Well, that is your tracker.
It's like your paste of whenyou work.
It's tracking everything.
It's tracking if yourdeductible has been met.
It's usually at the bottom ofthe EOB.
It's tracking what?
So let's start with.
It tracks the visit that youwere seeing.
Every visit that you wereseeing by a provider is.
They're going to send you anEOB every time or you're going
(25:03):
to get it electronically or inthe mail.
It's going to have that date.
It's going to have the providerthat you're seeing.
It's going to have the servicethat was done.
It's going to have what theprovider is going to charge you
or going to charge your card onfile.
It's going to have yourdeductible amount If it went
towards where you deductible orif it paid the provider directly
.
(25:24):
If it goes towards where thedeductible, then that's your
responsibility to pay thatprovider.
Or if you sign something sayingthat we can charge the card on
file, us billers will charge thecard on file for that
deductible.
It's going to let you know whatthey paid the provider, if they
paid the provider anything atthe bottom.
It's going to calculate howmuch you met towards where
you're at a pocket.
(25:44):
Let me tell you you're at apocket so important because once
you meet your out of pocket youhave no more co-pays for the
rest of the year.
You have no coinsurance for therest of the year.
Your appointments are coveredat 100%.
Now you want to track thatbecause providers can't track
that.
They don't Updated enough inthe system where we're going to
(26:04):
know all this patient met at apocket.
We don't know until you tell uswhat.
We get an EOB saying it waspaid at 100%.
Then sometimes we have torefund the patient.
So it's always good not tothrow that away because you'll
know exactly what your providerdid.
This is really big in emergencyrooms, not even outpatient,
(26:25):
because we all know theemergency room do charge a lot.
So I've had so many callsbefore working in emergency
medicine where like okay, thiswas double charge, this was
triple charge.
I didn't get this done becauseeverybody's moving so fast in
emergency room.
They were supposed to get itdone but now they're getting
charged for it.
So you want to read your EOBand you want to save them
(26:46):
because that is like yourencyclopedia of the insurance
world and also your medicalhistory of how much went towards
the word anything of yourinsurance.
So you never want to throw themaway ever.
Speaker 1 (27:00):
Okay, lesson learned.
Yeah, as soon as I heard it'slike a pay stub, I was like,
okay, this is an importantdocument.
Speaker 2 (27:07):
You know how you track your taxes on your pay
stub and you track how much yougot paid and how much they took.
That's exactly like a pay stuband a lot of people and they do
add a lot of, I can say, likeexcessive blue crosses.
It's like six pages.
The most important page is likeone page.
You can throw the rest away,but the page with everything on
it you're going to want to keep.
Speaker 1 (27:28):
Okay, good to know.
I will not throw another oneaway.
So how can someone like myselfor any of our listeners who are
wanting to use their healthinsurance for mental health
services?
How do they handle the billingand the claims?
Is there anything they need todo other than you know, just
(27:49):
calling their insurance companyto verify their benefits?
Is there anything they need todo on their end to use those
benefits?
Speaker 2 (27:56):
The most important thing is be very active in your
billing so you know you haveyour office, you have your front
desk staff that check benefits,you have your bill that it
bills out.
But it's always helpful whenclients check their benefits
themselves too to compare sothat there's no conflict when
(28:18):
the bill comes Like, oh, I gotcharges deductible I shouldn't
have.
And then you know us as billersare like well, this is what
your insurance said and they'relike well, my insurance said
something different.
So it's always good for themembers to make sure they know
what's going on and tounderstand that the insurances
do make mistakes.
They're not perfect and never,ever, just assuming the office
(28:40):
made a mistake.
I've been in this a long timeand I will never, ever not say
the insurances don't makemistakes.
They do, and when they makemistakes, they need to be held
accountable, and not thedoctor's office.
So definitely check yourbenefits before you're seen by
your provider.
You have access to everythingthat us billers have access to,
(29:02):
just in a different manner.
You have a provider, we have aprovider portal, you have a
member portal.
Everything in that providerportal matches whatever is in
that member's portal, so you cansee everything that we do at
all times.
That's something you should aclient should really, you know,
pay attention to.
They should really log on totheir provider portal at least
(29:23):
at the end of every month, justlike you go through your bills,
and you pay your bills at theend of every month or you have
certain dates set of time.
Make sure that you're goingthrough your claims, make sure
everything's correct, becausethen that also helps providers.
If the insurance makes amistake, then they can let us
know.
We can get it fixed.
Speaker 1 (29:39):
That's so great.
That answers my next questionwhat resources or tools are
available to help individualsreally understand and make the
most of their mental healthinsurance benefits?
And I think you nailed it righton the head the provider portal
.
So, if so, I'm assuming theprovider portal that's not
something that is or sorry, notprovider portal, member portal.
(30:01):
I'm assuming that's notsomething that's provided by the
physician or the therapist thatyou're seeing.
That's where your insuranceinformation lives, and the
people who own that portal arethe insurance companies.
So then you would just need togo to your insurance company's
website to log in and see thatinformation Correct.
Speaker 2 (30:22):
Yes, yes, yep.
You just have to log in, get ausername and a password and you
can see everything.
Any of every provider or everypharmacy builds.
Speaker 1 (30:31):
Awesome.
Okay, so I think we've gonethrough some pretty useful
information here.
I know I feel a little bitsmarter.
I would still probably call youif I got a little stuck in
navigating my insurance.
It's always helpful to have afriend who really understands it
and has been doing it for avery long time.
(30:51):
But in terms of utilizinginsurance to cover mental health
, I think the key takeaways wehave are you can do it.
You can choose whether you'regoing to look for an in-network
person and know exactly what isgoing to be charged and your
co-pay and your deductible, oryou can go out of network, where
it's more of a relationship andagreement between you and the
(31:12):
provider.
The insurance company doesn'treally get involved
contractually with the provider.
Really making sure you areadvocating for yourself and
aware of your own insurancebenefits so that there's less
likelihood of mistakes, and alsopartner in with your provider
and their billing office to stayup to date with changes that
(31:33):
are going on with your insurance, in case you are entitled to a
refund or something wasn'tsubmitted or the insurance
company made a mistake.
Really just knowing that andknowing that everyone is human.
It's not always the provider'sfault, it's not always the
insurance's fault.
I think we've really unpacked alot.
Explanation of benefits veryimportant piece of paper.
(31:56):
You want to keep that for yourrecord purposes.
Thinking of all that we'vetalked through, do you have any
tips or additional advice forlisteners who are currently
using their health insurance formental health care or
considering on doing that?
Speaker 2 (32:11):
Yes, I do.
First thing is know what you'resigning up for.
Know what benefit plan you'resigning up for, when your job or
you're on the marketplace.
Really understand.
If you don't understand, go toa friend that understands it.
Call the insurance company andhave them explain it to you.
I'm pretty sure there are alsopeople selling the insurance so
(32:34):
you can call them.
Understand what you're signingup for, because once you sign up
for it you can't go backwardsfor many, many months.
You're stuck with thisinsurance plan.
Know what you're signing up for.
I've even had my own familymember sign up for something and
I'm like why didn't you come tome first?
Now you signed up for the worstplan on earth and you're upset
(32:58):
because you're getting tons ofbills because you're not paying
any premium.
That means that on the back endyou're going to get charged for
everything.
Know what you're signing up for.
Make sure you know yourbenefits once you do.
Make sure you know what kind ofclinician that you're meeting
with, what kind of doctor you'remeeting with what, how the
(33:18):
whole billing process works.
Don't never be afraid to callthe office and ask to speak to
the billing office.
They should really be availableto you at least within 24 hours
of your call.
Ask questions.
Don't be afraid to ask anybilling questions to the
insurance company as well asyour provider's office.
Everybody should be there tohelp you.
Speaker 1 (33:39):
That's such a great call out and I can speak for all
of our team here at Kindermineand Michelle, who is our billing
and insurance guru.
We and she are always happy tobe here and answer your
questions and explain theinformation that we've received
when we checked your benefits.
(34:00):
But again, super important thatyou also reach out to your
insurance, verify that that'salso what you're hearing from
your insurance, so thateveryone's on the same page.
But absolutely that issomething that we value at
Kindermine is being here tosupport clients, making it
possible to use your insurance,so that you're not having to be
(34:24):
the one to figure that out andreally support clients on that
insurance billing in.
So then, all you really have tofocus on is therapy and your
mental health journey.
That is correct.
Well, thank you so much forjoining us today, michelle.
It was so great to see you andtalk to you and go through all
of these questions that I knowwe're super helpful for folks to
(34:46):
get the answers to.
Speaker 2 (34:47):
Yes, thank you, thank you for having me, absolutely.
Speaker 1 (34:54):
The Kindermine podcast is produced by Dr
Elizabeth Barlow, edited byMarco.
Antonio with music by PaxMinerva.
Thanks,
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