[MUSIC PLAYING] Glad you're with us. So let's get rolling. This lesson will cover payment terms and processes usually used by the insurance industry. These terms and processes can be very confusing for counselors, as well as clients. This unit will specifically cover deductible, coinsurance, copay, and collecting payment. Checking eligibility can confirm amounts for deductibles, copays, and coinsurances so that the client will have this information before counseling starts.
Clients may or may not have deductibles affiliated with their insurance. A deductible is typically an amount of money that a client must pay out-of-pocket that is on their own for their health care before an insurance company will cover medical expenses. The deductible is usually different from in-network services versus out-of-network services.
Now, in-network benefits are those provided to the subscriber who utilizes a provider that is in the network of this subscriber's plan. Out-of-network benefits are those provided to the subscriber who utilizes a provider that is not in the subscriber's network that is not paneled on the insurance plan.
Out-of-network benefits typically mean that the subscriber will have higher deductibles and copays and will need to pay more for their visits. When a client has an unmet deductible, he or she will owe the whole amount of the billed service. Be careful in this situation, as the client will owe the contracted amount negotiated between you and the insurance company and may be made more complex depending on whether a counselor is in- or out-of-network.
So say your rate billed for an intake session is $200. But the contracted amount with the insurance company is $125. The amount of the bill applied to the deductible will likely be $125. The remaining $75 is written off by you because you agreed to accept $125 payment from the insurance company. You with me? OK.
All right. Yes, it gets confusing. But the best practices is checking benefit eligibility beforehand. This way, you'll know your contracted rate and the client's insurance and can inform the client at the time of the service.
One more scenario, OK. It's also possible for a client to have met the deductible through services elsewhere, such as through medical visits or procedures. Thus, a client may only have a small remained deductible, say, $20 or so. So when that happens, you will receive a check for $105 from the insurance company. And $20 will need to be collected from the client.
Clear as mud, right? Well, good thing you can rewind and replay this 100 times. You may need to do that.
Even after deductible is met, there could still be a copay required. It's also possible for clients to have more than one insurance. Hang on there. In these cases, you'll have to have an owed amount from the first insurance billed to the secondary insurance.
In these cases, the secondary may cover none, some, or all of this amount. Why were you thinking of private practice in the first place? Really, go back and think about that-- that big question. Why? This becomes much less complicated as you get oriented to running your practice and even simpler if you can hire help.
Coinsurance is usually the amount that the client must pay after a deductible has been met or if there is no deductible. Coinsurance is typically a percent, such as 20%, of the total reimbursed amount for the session. The percent will be calculated from the contracted amount and not the amount billed. It's important to collect coinsurance monies at the time of each session when the amount is known.
So a client who has met their $3,000 deductible attends a counseling session. And you billed a session as an intake for $200. The contracted rate with the insurance company is $120, and the client has a 20% coinsurance. The insurance will reimburse you $86, with the client owing $24 for the date of service.
Does that makes sense? OK, good.
A copay is a fixed amount that the client will pay for the session as determined by the insurance company. Copays can either be the same as the PCP, or Primary Care Provider, amount, or they can be the specialist amount. The only way to know which copay to collect is to call the insurance company or check online.
Be sure and collect copays each session. At the end of all my sessions, if a copay is due, I pull out this little square thing and connect it to my phone. And I swipe a card.
Not charging copays or coinsurances is considered insurance fraud and is not allowed and can get you in very big trouble. The reason why is because you negotiated a rate with the insurance company, and the insurance company expects the entire amount to be collected. Not collecting copays, deductibles, and coinsurances from the client is considered insurance fraud.
Here's what we covered in this lesson-- first, deductible. Next, coinsurance, copay, collecting payment.
(05:44-06:15) Collecting payment