Understanding Insurance Coverage for Therapy
At Virago Wellness, we understand how much you pay for insurance and how important it is to be able to utilize the benefits you work so hard for.
We understand that navigating insurance benefits can be a bit of a nightmare. There’s a lot we do to work with our clients to help make it as easy as possible for them to utilize these benefits. It’s also important to us that clients understand insurance coverage.
Here’s some detailed information to help demystify the process and let you know what to expect when receiving services from Virago Wellness.
Each insurance provider has in-network providers.
Healthcare providers undergo credentialing to be contracted with each insurance provider separately. Any provider not contracted with insurance is considered out of network. Virago Wellness has set rates for services, but our contracts with insurance dictate what we can and can’t charge for clients under those specific plans. There are limitations to what we can and can’t do dictated by those contracts.
One important term to understand is medical necessity. In order to bill your insurance, therapeutic services must meet criteria for medical necessity. This means that your mental health would be negatively impacted if services were not provided. Just like your insurance won’t cover a cast for an arm that is not broken, coverage would be denied if therapy services are unnecessary. One way we determine this is through diagnosis of a mental health disorder. Diagnosis is a very complex issue and if you have questions, discuss this with your therapist directly. Insurances require a diagnosis on file to utilize coverage and benefits. It’s important to know that you do not have to utilize a diagnosis and you have the right to forgo use of your insurance to access care in ways that may be better suited for your personal goals.
For example, it’s not uncommon for a therapist to work with a client on an issue that ultimately resolves. As the client’s mental health improves, they may want to continue seeing their therapist for the benefit of having a space to talk through things regularly even though they no longer meet criteria for medical necessity. In these situations, we can switch to private pay to continue to provide the support.
Another aspect of insurance benefits that can be confusing is knowing what your insurance does and does not cover. This is dictated by your specific plan. It’s also important to know that most plans renew January 1st each year, but some may renew in June or September. If you ever have questions about your personal coverage, there should be a Member Services Phone Line listed on the back of your insurance card.
For in network coverage, you will either have a deductible, coinsurance, or copay. This determines what you owe versus what your insurance covers and is dictated by your personal plan. A deductible is a preset dollar amount that you pay out of pocket before your insurance benefits kick in. These can range from $500-$15,000 depending on your plan. Once you meet your deductible, you will either have a copay, a set dollar amount that you pay regardless of the cost of the service (usually $10-$40) or coinsurance. With coinsurance you pay a percentage of the cost of services and your insurance covers the remaining percentage. Again, these details vary plan to plan. It’s important to know that plans with a deductible reset at the renewal date. So if your coverage is Jan 1st-Dec 31st, your deductible will reset on Jan 1st.
We do our best to verify benefits and coverage for each new Virago client. Our Administrative Assistant Meg Terwilliger will call your insurer and find out the details of your specific plan so you’ll know exactly what to expect before your first appointment. If for some reason Meg is unable to do this before your first appointment, you can find this information out by calling the Member Services Number on the back of your card.
What if the clinician I want to work with is Out of Network?
If you are interested in working with a Virago Wellness clinician who is out of network for your insurer you have options. Some plans have Out of Network coverage. This may have a separate deductible, different coinsurance or a copay. You can also call and ask about a Single Case Agreement. A Single Case Agreement means your insurance will negotiate with us at Virago Wellness for a one time arrangement to cover services provided by your therapist. At Virago, we will always accept a Single Case Agreement that is in the range of our current insurance contracts and manageable administratively. We cannot accept Single Case Agreements that are below our typical rates. See below for more guidance on contacting your insurance company.
What if my coverage is interrupted or insurance makes a mistake?
Unfortunately this can happen for a variety of reasons. If you think your services were billed incorrectly or insurance made a mistake, let us know and we will investigate. Our policy is to make 1-2 attempts to get the error corrected. Ultimately we do have to default to the final say of your insurance. If for some reason your coverage is interrupted and this leaves you with a large bill, we can offer you a payment plan to work through the balance at a reasonable pace. If you ever need to file a complaint regarding your insurance, we can help inform you regarding that process as well.
What are the different services?
There are a few different types of therapy services we bill to your insurance. Typically these are based on the length of the session. These are the different services and their medical code numbers:
90791 Intake-first session 50-60 mins
90837 53-89 mins
90834 38-52 mins
90832 16-37
90847 Family therapy with client present
90846 Family therapy without client
Asking for Out of Network Coverage or a Single Case Agreement:
Contact Member Services (the number is usually located on the back of your card) to request one of two options:
1. Out of Network Coverage: Ask if your plan has any coverage for out of network
behavioral health care (mental health) services.
2. Ask if they will approve a "Single Case Agreement". It’s important to know that most insurances do not offer Single Case Agreements and it can be challenging to call and inquire about this. We want you to know all of your options but to also be prepared with realistic expectations. They may ask you which services you are requesting coverage for. Here are the codes used most commonly for mental health:
90791-Psychological Evaluation (this is your intake session, your first session)
90837-53-60 min psychotherapy session
90834 31-45 min psychotherapy session
You may also need your clinician's National Provider Identifier (NPI) number. Your clinician can provide this for you. If your insurance rep informs you that they will allow coverage, please ask for a REFERENCE NUMBER and provide this to your clinician.
Contact or clinician or Nikki at nikki@viragowellness.com with any additional
insurance questions.
