Understanding Health Care Insurance Reimbursement For Behavioral Health Care Services and Medical Necessity Guidelines.
Before choosing to proceed with using your traditional health care insurance for psychotherapeutic treatment, it is important to understand how health care insurance companies handle behavioral health services and reimbursement.
Currently, insurance companies only reimburse behavioral services for treatment that they deem ”medically necessary”, including mental health disorders and resulting functional impairment. Functional impairment means that your symptoms are preventing you from adequately being able to manage your personal or professional life without significant distress. Health care insurers require that providers monitor and document symptoms and diagnostic criteria and they track submitted diagnoses for payment. Therefore, it is ultimately up to compliance with medical necessity guidelines that determine justification for treatment and payment. They can request detailed information about your treatment at any point. It is important that you discuss the diagnoses being submitted for you to your insurance company with your provider, as it could in some situations affect the acquisition of employment, security clearance or a future purchase of insurance.
Unfortunately, treatment for other diagnoses or concerns such as phase of life problems, work stress, relationship conflict or stress, normal grief or supportive psychotherapy are often not considered ”medically necessary” and therefore, not reimbursable through insurance. For this reason, I can only accept health care insurance for patients with situations that meet medical necessity guidelines.
If you are seeking treatment for concerns that insurance would not consider medically necessary, you could consider using EAP benefits through your employer. These services are no-cost, and typically not typically subject to medical necessity requirements. They typically only provide for a few visits, but can help to clarify what assistance might be the most useful, and provide referrals for longer term treatment, if necessary. Additionally, you can consider seeking services at a non-insurance based sliding fee scale mental health training clinic, where the need to meet insurance company medical necessity requirements is not relevant. If finances are a concern, this is often much less expensive than treatment with private out of network providers.
Hopefully this summary will assist you in making an informed decision when considering using your health care insurance benefit for behavioral health care services. Be sure to ask any questions that you have, prior to commencing treatment. If you wish to be screened for medical necessity, please call the office at 310-472-3385 or email the office and you will be contacted with more information and next steps.