WS Insurance, Sliding Scale, & Payment FAQ

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1. How Does Insurance Work? What if I Do Not Know My Insurance Benefits?

  • Most clients do not understand their own insurance and benefits. WS does understand that clients are often confused by the insurance process so we have included extensive information on our website to assist you. We have provided information, resources, and our most frequently asked questions to try and empower clients to make informed decisions regarding their healthcare choices. We hope that this helps provide clients with the education and resources to feel supported. 
  • It is VERY important for clients to know their insurance benefits and their financial responsibility for care. In the legal world there is a saying, "ignorantia juris non excusat" (ignorance of the law excuses not) or "ignorantia legis neminem excusat" (ignorance of law excuses no one) and this is a fair analogy to remember with insurance and billing patient responsibilities. Clients are financially responsible for their care regardless of if they know or understand how their insurance works.
  • Clients are responsible to know their own insurance benefits. Clients who make the active decision to be willfully ignorant of their own outpatient mental health eligibility, benefits, claims, or the network status of the provider are still financially responsible for their benefits and patient responsibilities for treatment. 
  • Clients pay their insurance company to manage their benefits, answer their questions about their benefits, and keep track of their claims information. If clients have questions regarding their insurance then the client should contact their insurance company to obtain this information. WS is not responsible for knowing a client’s insurance benefits better than the client. Clients who have questions about their insurance or complaints about their insurance should direct those questions and complaints to the appropriate party - their insurance company. This is the client’s responsibility. Taking responsibility, ownership, and accountability for one’s own healthcare journey includes financial responsibility.

Please review the following resources to help you understand how the insurance and claims process works:

How Insurance Works (YouTube Video) 6 Minutes

Health Insurance Explained - The YouToons Have It Covered (YouTube Video) 6 Minutes

Understanding Your Insurance Costs (YouTube Video) 5 Minutes

The Health Insurance Claims Process (YouTube Video) 7 Minutes

The Basics of Medical Billing - Article

Medical Billing & Coding Vocabulary (Video) 7 Minutes

Medical Billing & Coding : The Medical Billing Process (Video) 11 Minutes

Medical Billing & Coding : Possible Errors & Problems (Video) 7 Minutes

The APA Guide To Mental health & Substance Abuse Parity (Equality) In Health Insurance (Article)

Mental Health America (MHA) : How Insurance Works (Booklet)

Mental Health Insurance (MHA) : How To Use Insurance (Booklet)

Mental Health America (MHA) : Deductibles, Copays, & Coinsurance Information (Booklet)

Mental Health America (MHA) : Paying For Care

State Laws Mandating or Regulating Mental Health Insurance Benefits

2. How Do I Check My Insurance Benefits?

  • There are two main ways you can check your insurance benefits.
  • The first is to call the member services 800 number on your insurance card. Follow the prompts necessary to obtain your outpatient mental health and substance abuse benefits. If you are unfamiliar with insurance basics it may be helpful to call and speak with member services to obtain this information so you can ask questions regarding your eligibility and benefits.
  • The second method is to go online to your insurance company member portal. If you have not used your member portal before then you will need to set up and activate your portal prior to obtaining your eligibility and benefits.

3. What information do I need to check my eligibility and benefits with my insurance company?

  • In most situations, the following information is needed to check your own insurance eligibility and benefits:  The current insurance card which will have the client’s Member ID and Group Number, the phone number for member services if you are calling your insurance company, the client’s date of birth, the client’s address, and the client’s phone number.
  • If you are not the client and you are calling for someone else then you will have to be someone that is permitted to receive this information. For example, a parent or guardian may call to obtain insurance, however; a spouse, friend, significant other etc may not check your benefits for you.
  • You may also need the following information for the subscriber on the insurance policy: The subscriber’s name, the subscriber’s date of birth, the subscriber’s address, the subscriber’s phone number, and in some circumstances you may need the subscriber’s social security number.
  • Also, it may be helpful to know the insurance CPT Codes that Wellness Solutions uses to submit insurance claims. The CPT Code for an Initial Psychiatric Evaluation is 90791. The CPT Code for Individual Psychotherapy 45 Minutes is 90834. These are the two most common CPT Codes used by Wellness Solutions.
  • If you are checking your insurance eligibility and benefits with your insurance company then you will be asked what service you are seeking. These two codes are used for individual outpatient counseling and psychotherapy for mental health and substance abuse.
  • The insurance company may ask for a diagnosis code. If you have not received any services and this benefits check is prior to your first session then it is completely acceptable to inform your insurance that you do not have one at this time. The insurance company is still able to check your benefits. A diagnosis code is a specific unique code number assigned to each diagnosis. In psychology all of the diagnosis and diagnosis codes are contained in “The Bible of Psychological Disorders” which is called The Diagnosis Statistical Manual - V (DSM-V). A diagnosis code is required to submit claims to insurance companies.
  • It is notable that there are some diagnosis codes that insurance will not reimburse for, however; we are well aware of the excluded diagnosis for most insurance companies and that does not preclude you from checking your own benefits.

4. What is a subscriber for an insurance policy?

Subscriber: The subscriber is the person who you are able to obtain insurance through. For example, if you are an adult who is on your mom’s policy because your mom’s work offers insurance benefits then your mom is the subscriber on the insurance policy.

5. I have XYZ Insurance- what are my insurance benefits?

  • If only it was that easy! Every insurance company will sell different types of insurance policies which will have thousands of different eligibility, benefits, and policy provisions. That is similar to going to a car repair show and asking how much new brakes cost for your car and expecting them to provide an accurate answer without them knowing what type of car you drive. 
  • We often are asked questions like, “I have XYZ insurance, how much is my copay,” or other similar questions. We are not able to answer because checking eligibility and benefits requires detailed information that must be verified with an insurance company. We are also not able to answer this question because one insurance company has so many insurance plans.

6. Can you check my insurance benefits prior to me signing the intake documents and scheduling an appointment?

  • Quite simply we cannot do that. But you can. Please see question 2 above for information on how you can check your own insurance benefits.
  • To check eligibility and benefits we must receive detailed information about your insurance plan and policy, the client’s personal information, and the subscriber’s information.
  • We are also required to obtain written permission to check your benefits. Therefore, we cannot check insurance benefits for any individual seeking treatment prior to receiving all intake documents signed and scheduling an appointment with a clinician.
  • Also, checking insurance benefits and receiving information about your insurance benefits is the responsibility of your insurance company. You pay your insurance company to manage your insurance benefits and to provide you with information about your insurance. Providers check insurance benefits for billing purposes. Insurance companies are the go to resource for their members (AKA clients) to receive information about the members’ benefits. 
  • Clients are responsible for knowing their own benefits.  Clients pay their insurance company to manage their benefits- make sure that you get your money's worth! The insurance reps are there for you. Clients often receive faster and more accurate information about their benefits than providers so it is important to check your benefits. 

7. I do not want to commit to signing any documents or scheduling an appointment if I do not know my financial responsibility for treatment. How do I know if I can commit to treatment if you cannot check my benefits prior to scheduling an appointment?

  • Good questions. We strongly encourage everyone to be empowered and informed consumers for the services they seek. Taking personal responsibility for your care is important to the treatment process.
  • We believe knowledge is power and making sure you are making the best decision possible includes evaluating all of your options, comparing these options to your needs, and understanding one’s personal responsibilities.
  • We recommend that you contact your insurance company and request your outpatient mental health and substance abuse benefits. Please see question 2 above.
  • You can also check to see if both Wellness Solutions and the clinician you are interested in scheduling an appointment with are in network providers or out of network providers with your insurance company.

8. What information do I need to verify if Wellness Solutions and my Clinical Associate are in network providers?

The following information may be requested by your insurance company to check the network status of Wellness solutions and your Clinical Associate:

  • Wellness Solutions, LLC Address: 26310 Oak Ridge Drive, Suite 5, The Woodlands, Texas 77380
  • Wellness Solutions, LLC Phone Number: 713-893-3989
  • Wellness Solutions, LLC NPI: 1922375484
  • Wellness Solutions, LLC Tax ID: 800221405
  • Clinical Associate First & Last Name

9. What is an allowable?

Charge: The complete fee a provider charges for a specific service.

Allowable: The amount a provider agrees to accept as a charge in order to be an in network provider with an insurance company. When a provider credentials with an insurance company the provider agrees to reduce his or her fees from the standard charge amount to the allowable amount. The allowable amount is then the fee used to calculate the client’s coinsurance.

  • The allowable for services changes between insurance policies. The allowable for one policy can vary for another policy by the same insurance company. Also, allowables differ significantly between insurance companies.
  • One reason we recommend considering an eligibility and benefits check to be a soft estimate until the first three claims complete the remuneration process is because most insurance companies provide incorrect information regarding the allowable for a policy.
  • Many providers choose to credential with insurance companies or not based on the average allowable set forth by the insurance company which a provider is required to accept to credential as in network.

Adjustment: The difference between the charged amount and the allowable is called the adjustment. This is the amount a fee the provider writes off in order to be considered an in network provider with insurance.

  • For example, if the charge amount for a service is $100.00 and the allowable for the service is $60.00 then the adjustment for the service is $40.00.

10. What is a deductible?

Deductible: The amount a client will pay prior to his or her insurance policy benefits activating. Deductible amounts and how deductibles work vary greatly between policies.

Individual Deductible: The deductible amount for each individual covered by an insurance policy.

Family Deductible: The deductible amount for every member covered by an insurance policy. If the family deductible has been met then the individual deductible in most policies no longer needs to be met.

  • For most insurance policies, the client must meet the amount of the deductible and then his or her copay or coinsurance will then be the amount paid for each session. For these policies, the client pays the full amount of the allowable for each session until the deductible is met.
  • For some insurance policies, the client will pay the copay or coinsurance which will go toward a deductible.
  • Client payments that go towards deductibles are not calculated on a dollar to dollar amount. Every insurance calculates the amount towards deductible differently.

11. What is the difference between a copay and coinsurance?

  • This is a very common question and there is a big difference between these two types of policies.

Copay:  A flat fee the client pays to the provider for service he or she receives. For example, if a client has a copay of $30.00 per session then he or she will pay that fee for each session.

Coinsurance: A fee the client pays to the provider that is a percentage of the allowable for the service he or she receives. For example, if a client has a coinsurance of 10% and the allowable for the service is $60.00 then the client is responsible to pay $6.00 per session.

12. What is an out of pocket (OOP) amount?

Out of Pocket: The maximum amount of money a client will pay towards his or her services. A client with an insurance policy with an out of pocket max amount of $2,500.00 will pay this amount and once it is met then he or she will pay $0.00 for services. This is also called a stop loss amount.

Individual Out of Pocket: The amount a client will pay individually towards services based on his or her policy. Once the individual OOP is met then the individual on the policy will pay $0.00 for services for the remainder of the benefit calendar year.

Family Out of Pocket: The amount an entire family on a policy will pay towards services. Once the family OOP is met then the family on the policy will pay $0.00 for services for the remainder of the benefit calendar year.

13. What is an insurance carve out?

  • Mental health and substance abuse benefits are often “carved out” to another insurance company. This means that the company on your insurance card which is the insurance company medical insurance is through is a completely different insurance company providing mental health and substance abuse benefits.
  • Mental health and substance abuse benefit carve outs are the most significant reason eligibility and benefits information is provided incorrectly. Eligibility and benefits checks do not give complete transparency and accuracy regarding mental health and substance abuse benefit carve outs.
  • This situation also provides significant challenges for a coordination of benefits (COB) problem. A COB problem with claims may occur because some insurance carve outs direct providers to send claims to the primary or medical insurance provider and some insurance carve outs direct providers to send claims to the carved out insurance company directly. If the primary or medical insurance fails to send the claim to the carved out insurance then claims can get incorrectly processed or remunerated. Equally as problematic is that insurance carve outs often have entirely different insurance information such as different member identification numbers and different group numbers. Therefore, when providers call the insurance carve out to obtain eligibility and benefits information the insurance company is unable to locate the client in their system. Insurance carve outs are a consistent confounding difficulty with mental health and substance abuse insurance billing.
  • Clients are responsible for knowing if they have a mental health carve out of their benefits. Many clients have insurance benefits that include a mental health carve out. A mental health carve out is when the client’s mental and behavioral health benefits are managed by a different insurance company than the client’s medical benefits. This means that the client’s medical insurance is managed with one company and their mental health benefits are managed with a different company. The name of the mental health carve out insurance company is usually NOT listed on the client’s insurance card. This can be confusing and complicated because if the client is not informed about his or her mental health carve out then the client will provide insufficient information to WS regarding their insurance. This causes problems with insurance claims being rejected or denied. This also causes problems because in many situations the mental health carve out insurance company is out of network. Clients may choose WS thinking that WS is in network with their insurance only to learn that is not the case because the client did not check to see who manages their mental and behavioral health insurance benefits. In this situation the client will provide WS with the medical insurance company information and the mental and behavioral health benefits are with a completely different company. The only way for a client to know if they have a mental health carve out is to check their outpatient mental health benefits. It is the client’s responsibility to know his or her outpatient mental health benefits. It is the client’s responsibility to inform WS if the client has a mental health carve out. If the client has a mental health carve out the client is responsible for informing WS of the managed care company’s information so WS can bill the client’s insurance correctly. 

14. What if I have Out of Network Insurance? What is sliding scale?

  • Clients Without Insurance or Clients With Out of Network Insurance- Payment Options. If a client does not have insurance or only has out of network benefits then WS provides two possible payment plan options. Option 1: The client can pay the full fee for services and then submit claims to their out of network insurance. WS will provide the client with a “super bill” which is required for the client to submit his or her claims to the out of network insurance. (Please see below for additional information). OR Option 2: The client can pay the sliding scale discounted fee for services. This is for clients who would not be able to access care or the cost of accessing care is prohibitive so WS provides a compassionate discount. This is an either or option. You cannot do both. This is not a WS rule, this is the law. A client can change his or her mind at any time. No, we will not back date to accommodate when a client changes his or her mind. The change will take place current and moving forward. If a client chooses a sliding scale then the fees paid for services will not go towards his or her out of network deductible or out of pocket. WS does not submit claims to out of network insurance. WS also does not check insurance eligibility, benefits, or claims for out of network services.

15. What is a Superbill? 

  • If a client opts to pay for the full fee for service and submit claims to his or her out of network insurance then WS will provide the required “superbill” documentation. 
  • The super bill will be provided no more than once per month, at the beginning of each month, and will be for the sessions in the previous month. 
  • There is a fee of $25.00 for WS to compile the information for each superbill. 
  • To request the superbill documentation go to the WS website - Click on Current Client Portal & Self-Service Forms - Click on the WS Documentation Self-Service Request Form - then complete the form. 
  • To receive the super bill the client must request the documentation each month. If a client misses a month then WS will not provide a super bill for the month missed. 
  • WS will not process documentation requests made without completing the WS Documentation Self-Service Request Form. It is the client’s responsibility to stay on top of the required information and documentation that he or she requires to submit their out of network claims to insurance.

16. How do I obtain receipts for payment? How do I obtain additional information regarding my patient account?

  • WS provides receipts via email every time a client’s credit card on file is charged. Clients are also provided with an account summary at the end of every month via email if there is a balance on the account. Clients can check their patient portal 24/7/365 for information on the balance on their client account. 
  • If a client would like any additional documentation regarding billing, such as, extra receipts then he or she needs to submit the request by going to the WS website - Click on Current Client Portal & Self-Service Forms - Click on the WS Documentation Self-Service Request Form - then complete the form. All billing documentation requests, outside from what WS already provides, will incur a $25.00 fee. Depending on the nature of the documentation request additional fees, such as case management fees may also apply. WS will not process requests made without completing the WS Documentation Self-Service Request Form.

17. Do you accept Employee Assistance Plan (EAP) benefits?

  • WS accepts VERY FEW EAP insurance benefits. If a client wants to access his or her EAP benefits then the client is responsible for calling their insurance company, obtaining the EAP Authorization Number, and the exact number of authorized sessions. The client will be asked to provide this information in the WS Billing Registration Form. WS does not contact insurance companies or EAP programs to obtain authorization numbers and the number of sessions covered. WS will submit EAP claims for clients for one treatment series only. Clients who have EAP benefits that can be renewed can only use those benefits with WS once. WS will not bill for repeated EAP series. Clients are responsible for calling their insurance company to obtain BOTH the EAP Authorization Number AND the number of authorized sessions to utilize and access this benefit. 

18. What is balance billing?

  • Balance Billing is illegal and in violation of contractual agreements for providers who are in network with a client’s insurance company.
  • Balance Billing is legal and acceptable business practice for providers who are out of network with a client’s insurance company.
  • Balance Billing is when the provider charges the client for the cost of the adjustment of a charged service.
  • For Example, if a charge for a service is $100.00, the copay is $30.00, the adjustment is $40.00, the insurance pays out $30.00 and the provider sends a bill to the client for the adjusted amount of $40.00 then the charge to the client for $40.00 is balance billing.

19. Can a provider waive a copay or reduce their fee for a deductible amount?

  • It is illegal and against contractual agreements for an in network provider to waive or reduce a copay.
  • It is illegal and against contractual agreements for an in network provider to waive or reduce a fee for a deductible amount.
  • An out of network provider may charge whatever he or she chooses for the services they provide and in most circumstances there are no regulations or restrictions.

20. What is the average amount of time that it takes for an insurance claim to complete the remuneration cycle?

  • The average amount of time it takes for an insurance claim to complete the remuneration cycle is between 14-30 days. Insurance companies vary on the average turnaround time between the date a claim is submitted to them electronically and the claim is processed completely.

21. If my insurance denied payment for a claim, who is responsible for the balance on the account?

  • If insurance denies coverage on any claim the balance will be billed to the client's account.
  • Clients are responsible for the services they receive. If the client has a rejected or denied claim then the balance belongs to the client. There is no guarantee that the client's insurance company will cover services. 

22. When will my credit card on file be charged for services? Can I request that a change to my credit card be moved to another day?

  • If a client opts for sliding scale or to pay the full fee for services and submit his or her own claims to their out of network insurance then the client’s credit card on file is charged the patient responsibility for services the day of the appointment. Payment for services rendered are due at the time of service. 
  • If the client uses their in network insurance then the client’s credit card on file will be charged the patient responsibility for services when the claim for each date of service completes the insurance adjudication process. Any other fees for services are charged to the client’s credit card on file as the client incurs these fees. 
  • Clients with credit cards that are declined will receive a $25.00 charge assigned to their existing balance.
  • Payment of fees is expected at the time services are rendered. It is the client's responsibility to know and understand his or her personal financial business including insurance policy provisions, eligibility, and benefits.

23. Are providers required to submit insurance claims to my insurance company? Are providers required to accept my insurance? 

  • No.
  • Wellness Solutions, LLC will check a client's benefits and submit this information to insurance as a courtesy. Submission of claims to insurance is not a requirement, as such, clients will be responsible for all fees not covered through insurance for rejected or denied claims and incorrect explanation of benefits. Wellness Solutions, LLC will not check benefits or submit claims to out of network insurance companies. The client and the client only is responsible for all fees for services regardless of insurance. This is the client's financial responsibility for treatment. 
  • WS does not submit claims to open access self-funded indemnity plans or similar insurance plans and benefits. WS reserves the right to refrain from insurance and claims submissions to companies or third party benefit administrators who do not provide adequate support to providers for insurance eligibility and benefits checks, claims follow up, electronic claims submissions, electronic remittance advice, or electronic funds transfers. WS reserves the right to refrain from insurance and claims submissions for companies who do not use the WS clearinghouse. 

24. What are the WS Communications Turnaround Time Expectations?

  • The WS Administrative, Appointment Management, & Clinical Turnaround Time Expectations Are As Follows:
    • Administrative, Appointment Management, & Clinical Texts: 2-3 Business Days
    • Administrative, Appointment Management, & Clinical Emails: 2-3 Business Days
    • Administrative, Appointment Management, & Clinical Patient Portal Messages: 2-3 Business Days
    • Administrative, Appointment Management, & Clinical Phone Calls & VM: 3-4 Business Days
    • Appointment Management Documentation Requests: 10-14 Business Days*
  • The WS Billing & Insurance Turnaround Time Expectations are As Follows:
    • Billing & Insurance Texts: 3-4 Business Days
    • Billing & Insurance Emails: 3-4 Business Days
    • Billing & Insurance Patient Portal Messages: 3-4 Business Days
    • Billing & Insurance Phone Calls & VM: 4-5 Business Days
    • Billing & Insurance Documentation Requests: 10-14 Days*

*Once the client submits the WS Documentation Self-Service Request Form. WS does not process documentation requests unless the client completes the WS Documentation Self-Service Request Form. 

*The WS communications turnaround time expectations may vary based on staffing.

25. Insurance Examples:

Example 1: A client’s eligibility and benefits check is quotes as follows:

Individual Deductible Amount:  $2,500.00

Individual Deductible Met to Date:  $1,520.00 (Not Met)

Family Deductible Amount:  $5,000.00

Family Deductible Met to Date:  $5,000.00 (Met)

Copay:  $30.00

Individual Out of Pocket Amount:  $10,000.00

Individual Out of Pocket Met to Date: $1,350.00 (Not Met)

Family Out of Pocket Amount:   $20,000.00

Family Out of Pocket Met to Date: $15,000.00 (Not Met)

Charge for Service:  $100.00

Allowable for Service: $60.00

The Amount Paid Per Session: $30.00

Explanation of Example 1: The client was paying the allowable amount of $60.00 per session until his or her family deductible was met. Once the family deductible was met then the client began to pay the copay for the service which is $30.00 per session. The client will pay $30.00 per session until the individual or family out of pocket is met. Once the individual or family out of pocket is met then the client will pay $0.00 per session for the remainder of the calendar year.

Example 2:  A client’s eligibility and benefits check is quotes as follows:

Individual Deductible Amount:  $2,500.00

Individual Deductible Met to Date:  $2,500.00 (Met)

Family Deductible Amount:  $5,000.00

Family Deductible Met to Date:  $3,250.00 ( Not Met)

Coinsurance:  $10%

Individual Out of Pocket Amount:  $10,000.00

Individual Out of Pocket Met to Date: $1,350.00 (Not Met)

Family Out of Pocket Amount:   $20,000.00

Family Out of Pocket Met to Date: $15,000.00 (Not Met)

Charge for Service:  $100.00

Allowable for Service: $60.00

The Amount Paid Per Session: $6.00

Explanation of Example 2: The client was paying the allowable amount of $60.00 per session until his or her individual deductible was met. Once the deductible was met then the client began to pay 10% of the allowable amount which is $6.00 per session. The client will pay $6.00 per session until his or her individual or family out of pocket is met. Once the individual or family out of pocket is met then the client will pay $0.00 per session for the remainder of the calendar year.

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