How Does Insurance Work? Is Dr. Goldberg & Associates In-Network?
How Insurance Works
How does insurance work? Great question! Insurance can be tricky, but in this article, we will outline the five main components of an insurance plan and how the claims process works.
What is the Difference Between In-Network vs. Out-of-Network?
If a provider or practice is in-network with an insurance company, that means that they have negotiated rates with the insurer for services they provide and have signed a contract stating they will accept the insurance and will be paid the rates agreed to in the contract for those medical services. That is why in-network providers can also be called “contracted providers.” The benefit of seeing an in-network provider is that you receive the contracted rate rather than the full, out-of-pocket rate.
To determine your coverage, you can call your insurance company to check that you have mental health benefits, they will ask you for CPT Codes, which are codes for each service a provider performs. Our most common therapy code is 90837. To learn more about CPT Codes, visit: CPT Codes
If a provider is out-of-network with an insurance company, they have no agreement and can charge you whatever their out-of-pocket rate is. Before you see an out-of-network provider, call your insurance to be sure that you have out-of-network benefits. If you have out-of-network benefits, you can get a superbill from the doctor’s office after you have paid out-of-pocket to be submitted to insurance for potential reimbursement based on your benefits.
What is an Insurance Premium?
The payment to purchase an insurance plan is called a premium. Sometimes your employer will cover some or all of the premium cost. Normally, the higher the premium, the better your benefits. This could mean a lower deductible or lower copay. Better coverage could also mean that your insurance covers more services, while cheaper plans may only cover catastrophic care like hospital visits, etc. Each person’s situation is different, so what may be a good plan for one person may not work as well for someone else. If you go to the doctor often, you may want a plan with a lower deductible.
Once the premium is paid, the insurance company gives you an insurance plan.
What is the Deductible?
Many plans have what is called a deductible. This is the amount of money you have to pay prior to insurance beginning to cover part or all of your medical claim expenses. For example, if you have a $1,000.00 deductible, you would have to pay $1,000.00 before your copay would apply.
You may be asking yourself, why have insurance if I have a higher deductible that I am never going to reach? One benefit is that although you have to pay your deductible first, the amount you pay is discounted to the contracted rate rather than the out-of-pocket rate. If a provider’s out-of-pocket fee is $200.00, but their contracted rate is only $130.00, insurance writes off the difference of $70.00. You get a discount of $70.00 in this example.
What is the Copay/Coinsurance?
Once you have met your deductible, you may have a copay or a coinsurance. A copay is a set amount that stays the same for all of your services. A coinsurance is a percentage, for example, 10% of the contracted rate. In the example used above, the contracted rate was $130.00. A 10% coinsurance would mean your responsibility would be $13.00 ($130 x 0.10) and insurance would pay the remaining $117.00. If you had a $25.00 copay, you would pay $25.00 and insurance would pay $5.00.
What is the Out of Pocket Maximum?
The Out-of-Pocket Maximum is how much total in a year you have to pay out of pocket before insurance covers 100% of your medical claim expenses. Once your deductibles and copays/coinsurances accumulate to meet this threshold, insurance generally starts paying for everything that is covered until your plan restarts the next year.
What is the Claims Process?
Once your session is completed, a claim is sent to your insurance company with the out-of-pocket rate for the session and the date of the appointment and other information that is needed for the insurer to determine medical necessity.
They receive the claim and adjust the rate down to our contracted rate for the services. Once the claim is adjusted, they review your benefits, and if your deductible has not been met, they drop the claim to your responsibility and count that amount toward your deductible. If your deductible has been met, they drop your copay or coinsurance to your responsibility and pay the remainder of the contracted rate to your provider. If your Out-Of-Pocket Max has been met, they pay for the whole claim and you owe nothing.
Once insurance has finished processing the claim, they send an Explanation of Benefits to you and an Explanation of Payment to your Provider with the payment for their responsibility of the claim. Once we know what your patient responsibility is, we will collect payment.
Is Dr. Goldberg & Associates In-Network?
Yes, we are in-network with Anthem, Blue Cross Blue Shield, CIGNA, and United Healthcare. We do not participate with Medicare or Medicaid plans. We accept insurance for therapy, medication management, and psychological testing and evaluations.
Call us today at (703)-935-0058 or email us at admin@drgoldberg.org to get scheduled!