Understanding Your Insurance Coverage

by Alan Brandis, Ph.D.

In the old days (pre-1990), insurance was pretty simple. You saw the doctor you wanted to see, the doctor submitted the bill, the insurance company paid 80% and you paid the 20% co-payment.

These days, health insurance is far more complex. (AAPA has two full-time employees who just deal with insurance issues!) We accept most of the major insurance plans, both traditional plans and managed care plans, and will bill your insurance company for you in most cases.

Many insurance companies now “buy” the mental health services portion of your medical benefit from another company, a "Managed Care" company, that specializes in mental health. This other company, for a flat per-person monthly fee, agrees to provide all the mental health services for all the people covered by the insurance plan in a certain area (this is called a "capitated plan" since it works on a per-head payment basis). They take the risk that it will cost them more to provide services than what they will receive from your insurance company. But, if there is money left over after they provide all the needed services, they get to keep it.

Managed Care companies try to keep the cost of insurance down by "managing" the care - that is, they try to make sure that only truly necessary services are provided to patients. The doctor has to justify, usually on a two- or three-page form every 5 or 8 visits, why any additional treatment is needed, by giving the managed care company clinical information about you.

This way of "managing" care arose, in part, because there have been some mental health professionals, including hospitals, who abused the insurance benefits, or who kept patients emotionally dependent on themselves for years. Our experience, however, is that most patients will be glad to terminate therapy when they are feeling better and their goals have been met, and that they let us know when this point has been reached.

Managed Care companies also keep insurance costs down by making contracts with doctors to accept lower fees, in exchange for getting a stream of patients. Doctors who do not get onto these Managed Care Panels do not get to see many patients, as more and more people are covered by such plans.

The effect of Managed Care on you, the consumer, is that the Managed Care company will tell you which doctors you can go to, and will tell your doctor which procedures can be provided, and how many visits can be used. Usually, your co-payment is low, and the doctor has to do all the paperwork, so it is convenient and affordable for you. However, you are limited in terms of who you can see for treatment, and if the Managed Care company decides you have had enough treatment, it will not authorize any more and your insurance will stop paying for it.

We believe that the decisions about treatment - what type of treatment, what goals should be set, how long treatment should go on, etc. - are best made together by you and your therapist.

When we recommend a procedure, such as psychological testing or a course of psychotherapy treatments, we believe that these prescriptions are the best remedy for the symptoms and concerns you came in with. We always try to work with your insurance company and your "Care Manager" to communicate to them the depth of the problem and the necessity for these procedures, but their criteria may not be to offer each person the "Cadillac" service if the "Yugo" service will get the job done "well enough." In such cases, you may be faced with a decision whether to continue what you feel are needed services even though your insurance company says it will not pay for them.

Why Do I Get Charged For A Missed Appointment?

Because most doctors are getting significantly less money per unit of service than they were getting 5 years ago, yet overhead (cost of office space, employees, etc.) keeps going up, and doctors now have to spend considerably more time doing paperwork (for which we do not get paid), when you miss an appointment without cancelling ahead of time it is more of a problem than it used to be.

If we sold computers, and you agreed to buy a computer but then changed your mind at the last minute, we could turn around and sell the computer to someone else. But, we sell our time (and, of course, the expertise that gets utilized during that time). Once we set that hour aside for you, if you don't use it and the hour passes, we cannot sell it to someone else since it is gone. And, we cannot bill the insurance company for a unit of service that was not actually provided. Therefore, the only way we can protect ourselves from the loss of precious time is to charge for time that is reserved for you but not used.

We feel that we have a fairly liberal policy, in that we only ask for a 24-hour notice if you will be cancelling your appointment. Some practices request a 48-hour notice.

If you have any further questions or concerns about our office policies, please call our office at (770) 953-6401. We'll be glad to answer your questions.