Let’s face it; times are hard with the economy on the brink of recession, downsizing, job burnout and stress. If you are lucky enough to be one of the millions of Americans with health insurance benefits, now is probably a good time to use it. However, insurance companies do not want to make it easy for you to make claims because, after all, they are a business. The insurance companies lose money every time you get sick or stressed out and need to see your doctor or therapist. In addition, until May of this year, it was still legal for private health insurance companies to discriminate against persons with stress or nervous conditions. Insurance companies did not have to provide mental health coverage at all. Or if they did, the copay could be twice the amount of a copayment you would pay to see an internist for a bad cold or the flu. The mental Health Parity law passed in May of 2008 is promising to change all of that. Some of these changes will be phased in over the next 5 years. But most people who are seeking help cannot wait 5 years. If you are one of those people who need help right now this article was written for you.
Most insurance companies whether its car, life, homeowners, or health insurance require steps to be taken by you (the consumer) prior to activating your coverage for any urgency. For the most part, with the regard to mental health, the following information must be obtained prior to seeing your doctor or other health care provider:
- Is an Authorization number required for mental health?
- Is a referral required from your primary care physician?
- What is the copayment or coinsurance amount for mental health services?
- Do you have a deductible and has it been met?
- Do you have preexisting condition?
If any of these terms seem confusing, you are not alone. Many patients avoid seeking treatment altogether because of this confusion and frustration. Hopefully, the following definitions will come in handy:
An authorization number is a long number with some letters mixed in usually between about 8-14 digits. It is basically like a confirmation number that shows that you are in the insurance provider’s database and you went through the proper procedure to contact them prior to seeing the doctor.
A referral is a form completed by your primary care doctor, which basically confirms to your insurance company that you really need the treatment that you thought you needed. In other words, the treatment is “medically necessary”.
A copayment is an amount such as 5 dollars 25 dollars or as much as 50 dollars. It’s generally a payment that helps the insurance company pay for your treatment. “Coinsurance” is just like a copay in that it is the amount of money paid to your doctor to help your insurance company pay for your treatment. The only difference is it is a percentage of what the office visit costs the insurance company. For instance, if the insurance company pays 100 dollars for an office visit, and 10% of that, then your coinsurance you pay to the doctor’s office will be 10 dollars.
A deductible is the amount of money you have to pay out of your pocket to the doctor’s office before your insurance company will start helping you pay for your treatment. For example, if your deductible is 500 dollars, then you have to pay 500 dollars to your doctor out of pocket before the insurance company will start paying for your treatment. Most of the time, after receiving 500 dollars worth of treatment the average person is feeling so much better that they may not even need to see the doctor anymore for the rest of the year. Nevertheless, every year, unless you change your benefits, you have to pay out that deductible before your insurance kicks in.
Most of this information can be obtained all at once by calling the phone number for mental health or member services on the front or back of your health insurance card. Preexisting condition information can be obtained by looking at your insurance contract or calling your insurance broker. You can also ask your personnel department at your job if “preexisting” will apply to your health coverage. You are probably asking yourself, “What the heck does preexisting condition mean?” From what we gather, it’s a medical problem you already had prior to getting your insurance policy. Only some policies have pre-existing clauses. Pray that your policy doesn’t. It basically means that if you have a broken foot and your preexisting clause says you’ve ever had a foot problem then your insurance will not cover any visits to your foot doctor. But your insurance company will never tell you that. Instead, they will give you all the referrals and necessary authorization numbers and tell you it’s ok to see the foot doctor. Then after your appointment is over and the doctor’s office goes to bill the insurance, your insurance company will come back (usually about 1 or 2 months later and tell you and your doctor that they will not pay any of your claims because you have preexisting. If you think it’s unfair many folks including myself, agree with you. If you are angry about it I suggest you write and complain to your congressman because for the time being it’s all perfectly legal in this country and in the state of Maryland.
So in summary, in order to effectively access the medical care you deserve, you must be on the same page with your insurer as well as the doctor’s office. If you have questions about the fairness or legality of insurance procedures you should contact your State Insurance Administration office or the state Attorney General’s office. These phone numbers for Maryland Insurance administration are 1 (800) 492-6116 and press prompts 4 and 0 for life and health insurance. The Governor’s office number is (410) 974-3901.
About the author of this article:
Kim B. Jones-Fearing, MD is a Board-Certified Psychiatrist in private practice in Burtonsville and Columbia Maryland.