Telebehavioral Health Insurance and Billing

Insurance plans may or may not cover telebehavioral health options. Contact the health insurance plan of each client to verify coverage, and then work with your client to clarify what is needed to accurately bill insurance.  Make sure you call the members services telephone number, found on the back of an insurance card, before the first counseling session.  Calling is important because online databases are sometimes out of date.  You want to confirm the following:

• Collect information about the “insured” (the policy holder) and the “client,”
• Make sure the health insurance benefits are active,
• Ask the client if there is a second health insurance plan (if yes, you must determine which plan is a primary plan and which is secondary, and then submit claims appropriately),
• Ask if you need an authorization and if there are any limits, copayments or deductibles associated with providing “outpatient” behavioral health care,
• Confirm (again!) what portion of the payment for the session your client will need to pay at the time of service,
• Ask how the insurance plan wants you to document the session on a claim (for example, clarify the CPT code, any modifier needed by the insurance company for this clients’ plan, place of service codes, and so on), and
• Ask if there are any “medical necessity” issues you should note,
• Explore issues about deductibles because you may be “sharing deductibles” with other behavioral health providers (for example, you need to know when the deductible is “used up,” how much of a deductible has been used thus far in the policy year, if the deductible threshold “resets” mid-year during the policy, and so on),
• Confirm the Usual, Customary and Reasonable (UCR) fee if you’re the “out-of-network,” provider (some insurance companies won’t share this information),
• Confirm the “out-of-pocket” maximum (this is the amount the client is required to pay before the policy pays one-hundred percent),
• Document this information and receive the name or identification number of the member service associate who helped you, and
• Review the information and specific amounts the client is contracted to pay you at the time of each service because a client may have different amounts due at different points during the course of treatment.  Have the client electronically sign or confirm they agree to their financial responsibilities.  If a copayment, co-insurance or cost-sharing fee is due at the time of the visit, make certain you collect this payment at the start of each session.

Pro tip:  When initiating care with a client, be sure that you follow all the same processes you would in an office-based practice, including intake paperwork required for billing and asking for a copy of their photo identification.

People desperate for care will pose as the policy holder in order to receive services, putting the provider at risk of fraud.