Insurance at Ebenezer

Filing claims with Commercial Insurance companies

 Are you thinking about using your insurance to assist with the cost of therapy?  Our therapists who qualify are able to file out-of-network claims with most commercial insurance companies like Blue Cross, UMR, UBH, UHC, Cigna, Aetna, etc. We do not file claims with TNCare or EAPs who only have in-network providers. Though TriCare usually does not cover us, if your policy has an Out-of-Network benefit, we can try to file claims for you.

Medicare

Medicare is complex! Though we cannot file claims with Medicare directly, we can file claims if you have a Supplemental Plan that has benefits for Opt-Out providers. Though most Medicare Advantage plans (Part C) only cover Medicare providers, we can try to file a claim for you to see if you policy will cover our services. With all Medicare plans, we have to send the claim with an “Opt Out Letter” which confirms that you understand that our providers do not participate with Medicare.

Important considerations for filing claims

The following will assist you in making the decision on whether or not to file and will help you understand how it works at Ebenezer.

 Diagnosis

Do I qualify? 

The first consideration for using insurance in healthcare is whether or not you qualify for a diagnosis.  Insurance companies operate on the basis of helping to pay for treatment of an illness.  This known as the medical model.  Most insurance companies honor the illnesses included in the International Classification of Diseases version 10 (better known as the ICD-10).  Insurance companies do not pay simply for you to talk with a counselor.  They only pay if you have been diagnosed with an illness and the doctor or counselor is treating you with an acceptable, approved treatment. 

 The ICD-10 contains a whole section on mental illness.  Examples include depression, generalized anxiety, stress disorders, and bi-polar disorders. There are many mental illness diagnoses.  If you qualify as having the symptoms of one of these, then a Diagnosis can be made for you.

 Many people seeking to speak with a counselor do not qualify for a mental illness diagnosis. Ordinary, but stressful life transitions do not qualify.  Neither do marriage issues unless one or both partners are distressed to the point of qualifying for a diagnosis.  So your counselor, during the intake phase of your work, will be assessing whether your cluster of issues and symptoms qualifies for a diagnosis approved by your insurance company.  If your counselor does not think you qualify, then you will not be able to use your insurance for seeing this counselor.

 Do I want a Diagnosis? 

Even if you qualify for a diagnosis, you might prefer not to have it on your medical record.  If you are diagnosed with a mental illness and you choose to file or have claims filed with your insurance company, then that diagnosis becomes a part of your medical record.  This can be an issue for people seeking security clearances and some life insurance policy applications seek information about mental illness as well as physical issues.  Many people do not want a mental illness diagnosis on their record and thus choose not to have claims filed with their insurance company.

 Your Counselor: Licensed or working Toward Licensure

Not all counselors can file insurance claims.  Counselors who are licensed by the state are qualified to file claims on your behalf.  Counselors who are working towards their license cannot file claims.  On the signs in our offices and on our website, you will see the words “Counselor in Supervision”  or “Social Worker in Supervision.” These therapists are not fully licensed yet.  Counselors have to go through a period of apprenticeship after the earn their Master’s or Doctorate degrees where they work under the supervision of a more experienced professional.  This is usually a two to three year period but can last longer.   Sometimes a therapist can get a temporary license which allows them to file insurance claims with some companies.  Not all companies honor the temporary license. 

 In-Network vs Out-of-Network Status

In-Network

To be clear, no Ebenezer therapists are in-network.  To be an in-network therapist, the counselor must be licensed and must submit an application agreeing to the terms for each insurance company with which they apply.  For the therapist, the advantage is that they are likely to get numerous clients wanting to see them because they are a part of the lower cost network.  The lower cost is the advantage for the client too.  Typically, a client will pay a set co-pay with in-network providers.

 The disadvantage for the therapist is that they are locking themselves into a contract where they will only be paid a portion of their fee.  So they have to see more clients in order to make the same amount of income as other out-of-network therapists.  Another major disadvantage Is that the insurance companies manage the therapy process more intensely for in-network therapists.  Typically, your in-network therapist has to justify getting approval for additional sessions periodically. 

 The problem here is that counseling does not often fit the medical model.  If you have an infection, your doctor diagnoses your condition and prescribes a treatment such as taking a medicine three time a day for ten days.  In contrast, most counseling situations do not have a simple prescribed treatment.  It is rare for your counselor to say you can be treated for your issue in five sessions.  People are more complex than that, and people’s life issues tend to be much messier.  So, most counselors do not like the regimentation and oversight/control of the insurance company. 

 Out-of-network

All Ebenezer licensed therapists are out-of-network providers.  This means that we can file insurances claims for you assuming that there is an applicable diagnosis and that you want for us to file. 

 Most insurance company plans include out-of-network benefits, but not all do.  When you present your insurance card at Ebenezer, we will attempt to verify your benefits.  If we discover that your policy does not have out-of-network benefits, we will inform you as soon as possible.  Sometimes though we will not know this until after we have filed several claims and gotten the Explanation of Benefits (EOBs) back from  your insurance company. 

 Deductible: Assuming that insurance company plan does have out-of-network benefits, it will almost always have a deductible and something called co-insurance.  The deductible is the amount of charges that your insurance company expects you to pay before it begins to help with therapy costs.  So if your deductible is $1,000, then you have to pay for the first $1,000 of charges before your insurance company will start helping with payments.  This deductible amount starts over every new year.  Typically, Ebenezer does not file claims if your deductible is greater than $5,000.  However, upon request, we can go ahead and file those claims even though you are not likely to get help with your counseling costs unless you have significant other out of network medical expenses.

 Allowed Amount: Another subtle but important complexity with deductible is that many insurance companies will not allow the whole counseling fee to be counted towards deductible.  The amount they allow varies greatly.  But you can see that if they allow only half the fee, then it will take a lot longer to reach that important deductible amount.  These rules are all a part of the contract you or your company has with the insurance company. 

 Co-Insurance: Once you have met the deductible amount, then you pay Co-Insurance.  For an in-network therapist, you would pay a Co-Pay.  For out-of-network therapists, you pay Co-Insurance.  Co-Insurance is the percentage of the allowed amount that the client pays.  This can be a bit complex and confusing since you the client are actually responsible for all of the fee that your insurance company does not pay.  So as an example, let’s say the fee is $140 for the session.  You have met your deductible, but your insurance company only allows $100 and your Co-Insurance is 30%.  This means your insurance company will pay 70% of the $100 that is allowed and you get to pay the rest.  In this example, the insurance company pays $70 and you end up paying $70 ($140 fee) even though your Co-Insurance is only 30%. 

 That previous paragraph might have your head spinning, but that illustrates the complexity of insurance policy reimbursement.  However, having them pay $70 is better than nothing, and this can be a big help especially if you are in therapy for a long time. 

 Summary Scenario

So as a summary example, you are seeing a therapist who can file insurance, you qualify for a diagnosis, and you want to go ahead with filing the claims.  Your insurance policy has out of network benefits with a deductible amount of $1000 and a Co-Insurance percentage of 20%.  (Your insurance company will pay 80% of the amount of the fee they allow after you have met your deductible.)  Now you are all set to go.  The Ebenezer Insurance Team will file these claims for you.  If there is a problem with the insurance process, we will inform you as soon as possible.  You can call your insurance company if needed.  And, in some cases, we can print out a “Superbill” that you can send your insurer if for some reason the claims Ebenezer files are not successful. 

 We on the Ebenezer Insurance team want to make this process of filing your claims as easy and simple as possible for you and your therapist.  Most of the time, the process goes smoothly and efficiently.  However, feel free to message the Insurance Department through your portal or to call us at 865 670-0988 ext 222 if you have any questions or information that we may need.  We will partner with you in this, and we wish you the best in your work with your therapist.

 Blessings to you,

 The Ebenezer Insurance Team