incurred are due in full at the time of service
a matter of ethics,
effort to protect your privacy,
to minimize unnecessary
a practical exigency,
will not bill your
organization for reimbursement.
unless otherwise agreed upon directly with Dr.
Payment is accepted as cash,
personal or bank check, debit or credit card.
You are free to submit claims for reimbursement
Dr. Garber will always provide documentation to
upon your request in support of this effort.
In full recognition that the costs associated
with un-reimbursed psychological services
can be substantial and burdensome, Dr. Garber
will gladly discuss
reduced fees, payment plans and alternative
services with you upon request.
Know your rights and representatives:
New Hampshire Insurance
Fruit Street, Suite 14, Concord NH 03301
NH TOLL FREE CONSUMER HOTLINE
|Health Insurance Today:
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
No matter the larger
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
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
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.
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.
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
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
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
|Health Insurance in
the State of New Hampshire
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
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
what does the law say about
your effort to appeal an insurance
NH law and a
US Supreme Court Ruling 6/2004
Health Insurance and Mental
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.
your insurance carrier or managed care
these questions today:
Always ask the voice at the other end of the phone,
your name and extension number?"
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 .
"I am (my child is)
beginning in psychotherapy.
Am I eligible to file a claim for reimbursement myself?"
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
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.
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 .
01.30.2009 NY Times article on HSAs here
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
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.
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
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?
rate of reimbursement depend
on who the provider is?"
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)?"
is the reimbursement rate for
'out-of-network ' providers?"
"Does the rate of
reimbursement depend on
a 'usual and customary' fee?"
companies will reimburse X% of the rate that
they deem appropriate, regardless of whatyou
paid. "Usual and customary" is the company's
way of saying what that dollar amount is.
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.
my co-payment and deductible be per visit
with an out-of-network provider?"
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.
the rate of reimbursement
depend on a PROCEDURE CODE or CPT?"
health service is assigned a CPT or procedure
code. Companies sometimes reimburse differently
depending on CPT. Individual psychotherapy is CPT
Learn more about NH CPT codes for
"What procedure codes
are NOT reimbursed?"
rate of reimbursement
require a DSM 5 DIAGNOSIS CODE?"
Insurance companies often require that the
identified patient be labelled with a formal DSM 5
(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
about DSM 5 here
The DSM 5
diagnoses can be found here
If a diagnosis code is
diagnoses are NOT reimbursable?"
the relatively benign diagnosis codes
(sometimes referred to as "V codes") are not
acceptable for reimbursement. For example, the
DSM 5 diagnosis code for Bereavement is V62.82
and for "Parent-child Relational Problem" is
"Where do I mail my
accept claims by
e-mail or fax?"
"How long will
it take to mail out my
reimbursements after receiving my claims?"
Now that you know the
what you are able and willing to spend to receive
the quality of care that you deserve.
This public website is
intended to provide general
information both about Dr. Garber's
and about select issues that
bear on child and family
development. None of the
information contained in these pages
can replace your well-informed
knowledge of your own child and
nor can it replace the first-hand
opinion of an informed professional.
the same token, weblinks are
provided here for general
without implying Dr.
Garber's endorsement or