Protecting Your Rights

 

About The Guild

What Is Psychotherapy?

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Some information on these pages
is adapted from the pamphlet
"Insurance Quandaries & Questions"
(Consortium For Psychotherapy).

Members of
The Psychotherapy Guild
are dedicated to
providing you
and your family
with the necessary
information to make
the choices that will
best meet your
mental health needs.


Considerations If You Choose
Third-Party Reimbusement

The following information may be useful to you if you choose third party reimbursement to pay for your psychotherapy.

1. You are encouraged to talk with your psychotherapist if you are considering filing for third party reimbursement. She or he can assist you in understanding the language and organizational procedures that accompany third party reimbursement and in reviewing the advantages and disadvantages of third party reimbursement versus self-pay.

2. Each insurance or managed care company has its own criteria for authorizing sessions. By seeking reimbursement from a third party payor, your psychotherapist may be required to provide information about your diagnosis and treatment to the company that administers the third party reimbursement. You are encouraged to discuss with your psychotherapist exactly what kind of information is being requested for both initial and continued authorization of benefits. Sometimes insurers will submit medical data to national data banks where the material then becomes accessible to other insurers and, potentially, to other parties. You should evaluate the possible impact for you or your family if this information becomes accessible to others.

3. The rules of confidentiality about how insurance and managed care companies record and use information provided to them may not conform to the customary and usual therapeutic norms of confidentiality. Although it generally is not the case, information contained in medical records maintained by third party providers may sometimes have possible implications for future employment, future insurance, security clearances, child custody and other legal involvements.

4. Third party reimbursement usually requires the routine and periodic exchange of information between your psychotherapist and the insurance/managed care carrier. Sometimes this information will be recorded in a computer data bank and/or transmitted via FAX or electronic communication. Your psychotherapist cannot guarantee that appropriate security measures are utilized by any insurance/managed care company regarding accuracy in the exchange and handling of such material.

5. Filing for third party reimbursement requires your treatment be "medically necessary." In such circumstances, your psychotherapist usually will be asked to assign a diagnostic label from the Diagnostic And Statistical Manual of Mental Disorders (DSM-IVR) to justify your treatment. It is advisable to discuss such diagnostic information and the implications of having a mental health diagnosis attached to your medical records with your psychotherapist.

6. Many third party reimbursement plans limit the number of sessions available to you. Your access to benefits is not necessarily guaranteed by many insurers. What you and your psychotherapist determine to be clinically appropriate for your therapy may not be consistent with the criteria for medical necessity as authorized by your insurance/managed care company. Therefore, the frequency and type of clinical services available to you may be restricted if you file for third party reimbursement, regardless of whether your psychotherapist recommends such services.

7. Your psychotherapist assumes responsibility for the timely filing of requests for additional sessions when you are utilizing third party reimbursement and for keeping you informed of the status of these approvals. Provided your psychotherapist fulfills these responsibilities, you may be expected to accept financial responsibility for direct payment of any charges which are not paid by your insurance or managed care company. However, some third party reimbursement plans place restrictions on services that can be offered to a client outside the framework of the contract that has been agreed upon between that company and the psychotherapist.

8. When you use third party reimbursement to pay for your therapy, you accept responsibility for any co-insurance and deductibles not covered by your health insurance policy. These charges generally are available upon inquiry from your insurance company or psychotherapist.

9. Some psychotherapists may charge an separate administrative fee to offset the additional time and paperwork involved in processing the requirements for third party reimbursement. Because insurance and managed care companies will seldom pay for such administrative fees, you usually will be required to pay such charges. Some third party reimbursement policies prohibit providers from charging this kind of additional administrative processing fee.

10. Many insurance and managed care companies restrict or deny third party reimbursement based on the credentials of the provider or the treatment method. The criteria for coverage generally are available upon inquiry from your insurance company. Your choice of psychotherapist may be limited to those who have a contract with your health insurance carrier. Some carriers publish a list of psychotherapists from which you are allowed to choose, some may assign you a psychotherapist, and others may allow your primary care physician to make the referral.

We hope you find the above information and concepts of choice, control and confidentiality helpful in making your decision.

 


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Copyright © 1999 The Psychotherapy Guild
Last updated May 1999.