Insurance is So Confusing! What does it all mean?

Yes, insurance is confusing. It's so confusing and reimburses so poorly for mental health care, that many mental health providers don't even accept it. At The Northrop Connection, however, we want to make mental health treatment as accessible as possible, so we take a good number of insurance plans, and we will work with you to the best of our ability to make sure that you can use your insurance to the highest available benefit.

Let's start out by walking through what happens when we register a new client who wishes to use their insurance.

First, we will talk with you about what your clinical needs as well as your insurance/payment capability, and we will match you to a Therapist/service that will best meet your needs.

Once we have identified your ideal providers, we will ask you to send a copy of your insurance card and to fill out basic information, including your clinical needs and relevant consent forms. Once we have received all of this, our Office Manager will check with your insurance to do a "benefits verification". When we do this, it confirms that your insurance is active and valid, and they should let us know if precertification is necessary (it almost never is) and what your expected copay/client responsibility will be.

Please note: The Northrop Connection sets a fee for services, but we have NO control whatsoever about your deductible, copay, or what you will ultimately owe to The Northrop Connection for services. Your copays and client responsibilities are set by your insurance plan.

Next, our Office Manager will let you know what that expected rate is, so you can plan appropriately. 

Then, you will have your first session, we will ask for payment of your expected copay, and we will file your insurance claim. Then we wait.

Now comes the bit that is frustrating for provider and client alike...the truth is that we never really know if your insurance is really going to pay until after you've had your session, we file the claim, and the insurance pays or denies the claim, which can take 2-6 weeks. We do employ a billing specialist to encourage the insurance to pay according to their agreement, but ultimately the insurance company decides what they will/won't pay. If we have hit a brick wall with regard to having the insurance company pay, we will sometimes ask you to call, only because they are sometimes more sympathetic to their customer (you).

Once all efforts to get your insurance company to pay for services rendered have been exhausted, it is your responsibility to ensure that your provider is paid for their time and expertise.

I do want you to hear that there is a pretty high percentage of the time that everything goes to plan: The insurance company properly estimates your out of pocket cost and they pay in a timely fashion, and we can focus on our clinical work. Insurance can seem like a problem, but it often works out just fine.

The following terms may serve as a "glossary" for "insurance-speak":

In-network vs. Out-of-Network:

• If your provider is in-network with your insurance company, it means that we have a contract to charge you exactly the terms of that contract. This means that we accept whatever the terms are of your plan. If you have a deductible, or a copay, or a coinsurance, that will be what we charge (more on that later). This is usually what is meant when you ask if we "take" your insurance.
• If we are out of network with your insurance plan, this means that we have no contract or agreement with your insurance company, and we charge our usual and customary rates as listed on our website. You will be responsible for the full fee of your session, and we will provide you with a "superbill" (see below), to submit to your insurance company to request reimbursement. In many cases, you can recoup 50-80% of what you have paid to us in this scenario.

Superbill: A superbill sounds a little more exciting than it actually is, but it is a specific form that you will need to request reimbursement from your insurance company for out of network services rendered. This form will include: the client's name/DOB/address, the date of service, the type of service, your diagnosis code, and the name/license number/tax ID of the provider. This will be provided to you via email, and you can send it out to your insurance company, usually through your member portal for your insurance company.

Copay: If we are in-network with your insurance company, you may have a copay of anywhere from $0-100 per session. The Northrop Connection is not responsible for setting this copay. Your insurance plans determines this amount, and it is the amount due for services rendered. We cannot waive or alter this fee, per our contract (or the law).

Deductible: Some insurance plans have a deductible that must be met before insurance starts paying providers. This amount can be anywhere from $500 to $10,000. The deductible resets each plan year. If you have a deductible to meet, it means you must pay the full fee of your session until that deductible is met. You meet your deductible with every medical appointment/procedure you have, not just your therapy appointments.

Coinsurance: Some insurance plans rely on a percentage fee split, which means that the client may pay for example 30%, and the insurance will pay the other 70%. This is called a coinsurance and would be your payment responsibility in lieu of the copay.

Benefits check: When you schedule an appointment with us, our Office Manager or Billing Company (Headway) will check your benefits, meaning that we will directly call your insurance company to get an estimate of the client cost share. We will pass this information on to you and will use it as the basis for your charges.

Marketplace: The Marketplace is the type of insurance available through the Affordable Care Act, also referred to as "Obamacare". If you are not offered insurance through a parent, spouse, or your own employment, you are eligible for this type of insurance. There are many plans available and subsidies available to make this insurance quite affordable. If you have tried to seek insurance through the Marketplace prior to 3/2021, you may have found that it was actually not all that affordable. However, the subsidies to the Marketplace have been expanded with federally funded stimulus bills. If you do not have insurance, I strongly recommend that you seek insurance through www.healthcare.gov. The Northrop Connection is in network with Caresource via the Marketplace. 

Commercial Insurance: If you have an insurance through your or your family member's employment, this is a "commercial" plan. The Northrop Connection is in network with United Healthcare, Oxford, Oscar, Blue Cross/Blue Shield, Aetna, Cigna, and Humana commercial plans.

Medicaid: Medicaid is a state insurance that is available to minors, people with certain disabilities, and is income based. The Northrop Connection is not currently in network with Georgia Medicaid. Per rules associated with Medicaid, people who have Medicaid cannot pay for any healthcare out of pocket, or they are at risk for losing their Medicaid.

CMO: CMO stands for Care Management Organization. This is a type of insurance that many children who are eligible for Medicaid will utilize. The Northrop Connection is in network with Caresource but not with any of the other CMO insurance plans.

Medicare: Medicare is a federal insurance plan that is available to people who are aged 65 and older, are blind, and who have certain types of disabilities. It is not income based. The Northrop Connection has providers who are in network with Medicare.

Please know that in a perfect world, we would never need to discuss payment for services. We would love nothing more than for our clients to get free mental health care and for us still to have a solvent business and to make our living. This just isn't possible, unfortunately. In order for us to continue to offer our services, we do need to make sure that our financial health is in order. If you are ever in a situation where your finances/insurance changes, and you need a sliding scale, let's please talk about it. We are here first and foremost to serve our community.

Questions? Please reach out to our Office Manager, Angie Downing or the Practice Owner, Jessica Northrop at 678-332-7955 or via email at [email protected] or [email protected].