The health care industry has changed dramatically over the past twenty to thirty years. Today's typical health insurance company is a very aggressive business looking to save money in the interest of increasing profits. When computer manufacturers or barbers or car mechanics or psychologists cut corners, reduce quality and quantity of services and increase consumer cost, consumers react by spending their money elsewhere, forcing these businesses to change their practices. Unfortunately, these same market forces have not impacted the health insurance industry as it continues to increase costs to you even while eroding the quality and quantity of service.

No matter the larger socio-political-economics, the day-to-day reality is the same. Your health care is no longer a private matter between you and your health care provider (physician or therapist, for example). In all but a few instances, for-profit managed health care corporations stand between you and your health care provider's recommendations. Managed health care employees who will never meet you, who will never examine you, and who may even refuse to talk to you commonly have the ability to deny you the care that highly qualified health care providers recommend.

Managed health care companies restrict your care and thereby increase their profits in a number of specific ways. It may be important for you to learn which, if any of these business models may be determining who can care for you and how:

1. Indemnity insurance is how all health insurance was fifty years ago. Under an indemnity policy, the patient sees whatever provider he or she prefers, receives whatever care the provider recommends for however long it is recommended and is reimbursed for most or all costs with no questions asked, up to a reasonable per-year or lifetime benefit maximum. 

2. Preferred Provider Panels are typical of PPO (Preferred Provider Organization) managed care plans. A PPO makes its money, in part, by allowing patients only to be seen by providers who have contracted to work within the PPO plan. In a PPO, providers agree to accept lower payments per service in exchange for a higher number of referrals through the plan. This means that providers must see more patients per day to maintain an income level, often compromising on the quality of your care.

3. Health Maintenance Organizations (HMOs)  are closed networks of providers intended to meet every health care need within a single organization. Patients who participate in HMOs typically enjoy relatively low premiums, co-payments and deductibles but may find that they have no benefits outside of a more or less limited group of providers.

Click here to learn which companies offer HMO plans in New Hampshire

4. Point of Service (POS) plans may cost more in premiums, but offer you more, as well. Most POS plans invite patients to see providers on a preferred provider list (as above) with minimal co-payments and deductibles and allow patients to see "out of network" providers (those who are not a part of the preferred provider network) for somewhat higher co-payments and deductibles.

5. Capitation shifts the profit-loss dilemma back to the provider. Under a capitated health care arrangement, an insurance company pays a provider a fixed amount of money to meet the health care needs of a specific population for a specific period.

For example, Alpha Insurance pays obstetrician Dr. Smith ten thousand dollars to deliver all of the babies born in Metropolis in a calendar year. If no babies are born, Dr. Smith banks ten thousand dollars for no effort. If ten babies are born, he is effectively paid one thousand dollars per delivery. If one thousand babies are born, he may work non-stop through the year and be paid ten dollars per delivery, no matter whether every delivery is a life-threatening C-section or a fifteen minute uncomplicated labor. Under capitation, providers must consider their own pocketbooks every time a test is ordered or a procedure completed., creating  one of the many unacceptable conflicts thrust upon patients and providers alike under managed health care.

You do have rights. You have a right to appeal any healthcare decision directly to the managed care or insurance agency. Appeals based on a provider's unique services in your geographic area or on a patient's pre-existing relationship with a provider regardless of network status are sometimes granted.

Click here to

Reach the New Hampshire Insurance Department

In New Hampshire, you may also appeal any healthcare decision or complain about any insurance-related healthcare practice (denial, limitation or payment) to the state insurance commissioner:

BUT ... what does the law say about your effort to appeal an insurance denial? NH law and a relevant US Supreme Court Ruling 6/2004

Health Insurance and Mental Health Care

Your health insurance very likely imposes restrictions on the type of psychological services you are eligible to receive and on the allowable duration of such services.
 
Your health insurance likely requires that the confidential matters which arise in the course of participating in psychological interventions be reported to uninvolved and often clinically naive third parties (e.g., managed health care case reviewers) and that the identified patient (yourself or your child) be categorized and labeled using medical terms suggesting the presence of an illness. These inflammatory and often misunderstood labels are recorded as part of the patient's electronic file. Even the 1997 federal HIPAA laws very likely do not adequately protect this data. 

Your health insurance or managed care company requires that participating providers complete reauthorization review procedures on paper, by phone, e-mail or fax which are often very time consuming and highly intrusive, hurdles which can stand between you and the continuation of psychological services.

1. Always ask the voice at the other end of the phone,

Write it down. Write down every answer you receive. Don't be intimidated. Ask for explanations of anything you don't understand. Ask to speak to a supervisor if you are not happy with the answers you are getting. You'll need careful records later if the company fails to follow through with what they've told you .

2. Ask,

Many insurance companies and HMOs will only accept claims for reimbursement directly from the health service provider him- or herself (that is, the physician, nurse, psychologist or other professional providing care).

If "NO," then complain loudly and find a new policy or carrier. The only reason some insurance companies and HMOs refuse to accept claims from you, the patient, is for their convenience. 

Keep in mind that your out-of-pocket medical expenses can be minimized if your employer offers a pre-tax medical "health savings account" or HSA.

Learn about the IRS rules regarding HSAs .
Read a 01.30.2009 NY Times article on HSAs here

3. If you are eligible to file your own claims with your insurance carrier, then ask,

"Can I be reimbursed for services already provided?
Or do I need PRE-AUTHORIZATION in order to be reimbursed?"

Many health insurance and managed care companies will not even consider reimbursing you for services provided and paid for PRIOR to your call. They will require that you receive their authorization first.

4. If you are eligible to file claims for reimbursement, then ask,

"What is the rate of reimbursement?"

That is, what percentage of the money that you spend will be reimbursed to you? 

For example, if you spend $100 out-of-pocket for one hour of individual psychotherapy  and then submit a claim for reimbursement, should you expect to get the full $100 reimbursed? Probably not. How much will be reimbursed?

5. Now ask,

"Does this rate of reimbursement depend on who the provider is?"

Some companies have a list of "preferred providers." If so, then ask,

"Who is on your list of preferred providers
in my immediate area with
expertise in ... (state the nature of your concerns)?"
and

"What is the reimbursement rate for
'non-preferred'
or
'out-of-network ' providers?"

6. Ask,

"Does the rate of reimbursement depend on
a 'usual and customary' fee?"

Many companies will reimburse X% of the rate that they deem appropriate, regardless of what you paid. "Usual and customary" is the company's way of saying what that dollar amount is. 

For example, your company may say that they will reimburse you 80% of their usual and customary fee. You paid $100 for one hour of psychotherapy and submit a claim for reimbursement. If the insurance company's usual and customary fee for individual psychotherapy is $60, then you will be reimbursed 80% of $60, or $48.

7. Now ask,

"What will my co-payment and deductible be per visit with an out-of-network provider?"

A co-payment is the (fixed or percentage) amount you owe to the provider per service, before reimbursement will be considered. A deductible is the total dollar amount you must pay per person or, in sum, per family, per year, before reimbursement will be considered.

8. Ask,

"Does the rate of reimbursement
depend on a PROCEDURE CODE or CPT?"

Every health service is assigned a CPT or procedure code. Companies sometimes reimburse differently depending on CPT. Individual psychotherapy is CPT 90806.

Learn more about NH CPT codes for psychologists here

Now ask,

"What procedure codes are NOT reimbursed?"

9. Ask,

"Does the rate of reimbursement
require a DSM IV DIAGNOSIS CODE?"

Insurance companies often require that the identified patient be labelled with a formal DSM IV (psychiatric) diagnosis.This label is recorded with the patient's name suggesting the presence of a mental illness.  For example, Attention Deficit (Hyperactivity) Disorder is 314.01

Learn more about DSM IV here

The DSM IV diagnoses can be found here

If a diagnosis code is necessary, ask:

"What diagnoses are NOT reimbursable?"

Often, the relatively benign diagnosis codes (sometimes referred to as "V codes") are not acceptable for reimbursement. For example, the DSM IV diagnosis code for Bereavement is V62.82 and for "Parent-child Relational Problem" is V61.20.

10. Ask,

"Where do I mail my claims?"
and
"Will you accept claims by
e-mail or fax?"
and
"How long will  it take to mail out my
reimbursements after receiving my claims?"