INSURANCE 

Insurance Coverage

Insurance plans can change and many insurance carriers offer multiple plans, so it is important that you verify your benefits directly with your insurer. Many health insurance plans do reimburse for our services as a non-participating ("out of network") provider. We understand the expense involved with psychotherapy and the need for many to utilize insurance to help cover the cost of treatment. We strive to make this process as easy as possible and to enable you to effectively utilize your insurance benefits.

Due to the number of different insurance companies and the differences in policies, it is difficult to generalize insurance company coverage and practices. Your insurance carrier is your best source of information on your specific benefits. Insurance companies may have ten or fifty different plans. Each of them may have a different coverage for mental health care. Some of them may be “carved out” to a third party, which in turn has multiple levels of contracts with different providers. Some of those third-party companies have now merged, changing the contracts even more.

Insurance Policy Statement

You may be told we are a covered office, but the person on the phone with you from your insurance company may be looking at a list from last week. The company may have changed the formulary for coverage yesterday. You are told you must pay your co-pay. You are not informed you still have a huge deductible that you owe, and they will not pay for your care until you pay that. You come in thinking that we only need to be paid a small amount, and we discover that there is a much bigger amount owed. Or, worse, that they were wrong, and when we called, they we wrong, and you are not covered at all.

We have had claims denied that were “confirmed” for coverage when we called for verification. Therefore, we call the families and inform them that we are going to have to enforce the contract with them that states that if the insurance company does not accept responsibility for the fees that the client is responsible for the entire bill.

Trust me when I say none of us likes those moments. We are in this business to help people. We don’t want to tell you ten visits later that you have no coverage. But we have no control over any of it. Some companies take six months to reply to billing. We can’t speed them up - we are at their mercy as much as you are.

But we are stuck. We must pay our bills and pay the staff and the therapists that work closely with you. We must be able to cover our costs and to be able to keep our doors open.

Therefore, please note: If service gets denied by your insurance company you are fully responsible for that service.

We are currently a contracted provider with IEHP, Anthem Blue Cross Medi-Cal, Aetna, Optum/United Health Care Aetna, Cigna, Beacon, and Kaiser. If you have a policy through one of these carriers, we accept reimbursement as in-network providers. Depending on what your insurance policy states, you may either have a deductible to meet before services are fully or partially covered, or you may only be responsible for the copay or coinsurance associated with your policy. Please verify with your insurance whether or not you have a deductible for an in-network provider.

With all other providers we are considered an out-of-network provider and you may pay higher costs than you would with an in-network provider. With these policies, you will be responsible for payment of our session fee at the time of treatment. Your insurance company will then process your claim and provide any reimbursement to you. We can assist you in submitting your claim either by submitting an electronic claim at the time of treatment or by providing you with a “Superbill” that you can submit to your insurance carrier. You are strongly encouraged to contact your insurance company at the number on your insurance card prior to receiving any services in order to understand your benefits and your responsibility of any incurred charges.

Questions to Ask Your Insurance Company


Insurance / Reduced Rates

Services may be covered in full or in part by your Employee Assistance Program (EAP), health insurance or employee benefit plan. In such cases, you may be required to pay a copay or coinsurance fee. In the event you consent to insurance claim payments, you also consent to rare but permissible insurance audits of your medical record. Please check your coverage carefully by asking the following types of questions to make an informed decision before choosing the best method of payment for you.

When you speak with your insurer, here are some of the important things to ask:

  • Do I have behavioral health insurance benefits?

  • What is the name of the company that pays my behavioral health benefit? (It's not always what your insurance card states.)

  • What is my deductible?

  • How much of my deductible has been met this year?

  • Do I have a copay and/or coinsurance?

  • What is my copay per session?

  • Do I have coinsurance in addition to or in lieu of a copay?

  • What is the rate for service codes 90791 and 90837?

  • To whom is the check cut--the subscriber or the provider?

  • How many sessions per year does my coverage allow?

  • Is Positive Methods (Business NPI # 1306296876) an active provider for my behavioral health benefit?

  • If not, is (provide clinician name) an active provider for my behavioral health benefit?

  • If not, do I have out-of-network coverage?

  • Are there exclusions (e.g., court-ordered therapy, telemedicine/virtual sessions, work-related injuries, etc.) associated with my coverage?

  • If my insurance lapse or terms while I’m receiving treatment, who is responsible for the fees subsequent to the lapse or term date?


Why Do Individuals Opt Out of Using Insurance for Mental Health Services?


This is an excellent question. Here are some reasons why some individuals choose to opt-out of using their insurance:

  1. Lack of Privacy and Confidentiality. When insurance companies pay for your treatment, it also means that their employees (clinicians or not) will audit treatment plans and read what is talked about in session notes.

  2. Assumption of Illness. Insurance companies operate on a medical model, which means they require a diagnosis to establish that you have “a medical necessity” to seek services in order to pay providers. The vast majority of insurance companies don’t consider relationship issues, existential issues, life transitions, personal development, or self-improvement as “a medical necessity”.

  3. Negative Consequences in your Future. If given a diagnosis, the diagnosis will become a part of your medical record. While that might not be such a big deal right now, it may become one later on if you want to: get life insurance, work in the financial sector managing other’s assets, regularly handle firearms, or seek employment in any sector in which your decision-making might be called into question due to your emotional state.

If the patient requests a restriction from using his/her insurance. An attestation will need to be signed.