If you are reading this article, you may have already made several calls to different psychiatrists trying to get an appointment. You may have been told that the doctor no longer accepts your insurance or is not accepting new patients. Occasionally you may have heard that some offices no longer accept insurance at all. Or you may have noticed very long waiting lists to get appointments. It is 2015 and it has now been several years since the affordable care act and mental health parity laws were passed during 2008 and 2010 respectively. These are federal laws that were passed in an honest effort to improve patients ability to get and afford health care. Some billing staff at large hospitals have noticed improvements in the number of patients who have insurance. However, as you may have noticed, it may be difficult to find outpatient physicians, especially psychiatrists, who accept your insurance. Insurance rules for psychiatry practices remain more complicated and difficult to use both for patients and mental health providers. Therefore, many practices have had to make difficult decisions, including stopping taking insurance, in order to keep their practices open and keep focusing on helping patients get well.
HIPAA (Health Insurance Portability and Accountability Act) further impedes the ability of mental health professionals and patients to be on the same page regarding each individual patients insurance benefits. Patients are often left “holding the bag” with an unexpected bill because they were never included in the process of activating their insurance. For this reason, I have created a process that gets all of my patients who are using insurance very clear and comfortable about what to expect their insurance to cover and what part they can expect as their patient responsibility (the portion the patient must cover out of pocket). Some of the vocabulary below may be helpful to know as you prepare for your, or a loved one’s, appointment:
Deductible – This is the amount of money that must be spent at the doctors office BEFORE your insurance will “kick in” and start paying for any of your treatment. If you have a “high deductible plan” this means you may have to pay as much as $5,000 out of pocket before your insurance kicks in. Think of it like pay as you go until you have spent $5000. Most people will not spend that much money during a year unless there is an admission to a hospital, an accident or a surgery or something else catastrophic that has happened during the year. The affordable care act placed a cap on how high an insurance deductible can be.
Copayment – The dollar amount that you must pay at the doctors office. This is also considered the “patient responsibility” portion of the office bill.
Coinsurance – This term confuses many patients because it does not mean a second insurance. It simply refers to an amount the patient pays “patient responsibility” which is a percentage of what the insurance company’s contracted rate is. For instance, if the contracted rate for a visit is $100 and the coinsurance is 20% then the amount owed at the time of the visit would be $20.00. Sometimes the insurance company will not be willing to tell the patient what their contracted rate is. Some think this may be because they do not want you to know how low their rates are.
Prior Authorization for Medication – This is a very long and frustrating process that the pharmacy benefits management company (your medication insurance company) forces doctors offices to go through in order for them to “approve” your medication. Medications that are expensive, new, or controversial often are sent through this process for approval. Sometimes medications have to go through this process because the company did not purchase them in bulk or obtain a lucrative enough wholesale contract for purchasing the medicine. Prior auths for medications can sometimes take weeks to get approved. Most doctors would do almost anything possible to eliminate the need for prior authorization. However, sometimes it is not in the best interest of the patient to simply switch medicines. Patients are vulnerable to getting sick again when forced to switch from a medicine they were stable on to a different medicine just because the insurance company says so. Therefore, a new law in this state was passed that limits the ability of insurance companies to require some prior auths.
These are the most frequently asked questions about insurance. If you have further questions, you can talk with your treatment provider or psychiatrist at your next appointment.
About the author of this article:
Kim B. Jones-Fearing, MD is a Board-Certified Psychiatrist in private practice in Burtonsville and Columbia Maryland.