When is an In-Network Therapist Not an In-Network Provider?

by Michael Reeder on April 17, 2014

When is an in-network therapist not an in-network provider?

If a provider says they are paneled with your insurance company, they are right?  Right?

Maybe they are not.

One answer is:  When the insurance company has outsourced mental health benefits to a 3rd party.

A 2nd answer: If the provider does not participate in all of the insurance companies’ plans.

So, say you have CareFirst Blue Cross Blue Shield (BCBS).  I am a CareFirst provider and I believe that I currently accept all of their various plans (HealthyBlue, BlueChoice, PPO, HMO, etc.).

CareFirst (and many others) are in the habit of outsourcing mental health benefits to another company.  I am aware of CareFirst BCBS outsourcing to APS, Magellan, and Value Options.  Sometimes CareFirst seems to handle mental health coverage themselves too.

Happily I am currently also a provider for APS, Magellan, and Value Options.

Some providers may choose not to handle all CareFirst plans as different ones pay at different rates.  This is one situation in which the provider might not take your coverage.

Another situation is where the provider is not in the network of the outsourced subcontractor.

So, for example, I recently had someone approach me with Anthem Blue Cross insurance out of California.  I can normally take all variants of BCBS nationwide.  However, this particular plan outsources psychotherapy to United Behavioral Health (UBH).  UBH has had their panel closed (not accepting new providers) in my area of Baltimore, Maryland for years.  No dice.  I’m out of network even though the client’s card says Blue Cross on it.

This is a really confusing situation for providers and clients.  I thought I could take all BCBS.  But… not if a plan from a different area of the country outsources mental health to a company I don’t contract with.

Happily I have a billing team who can easily do a preauthorization check of benefits for both of us.  Such preauthorizations are best estimates of coverage but are usually right.  So one of the advantages of utilizing my services is that I can have your coverage checked before you walk in the door in order to help with budgeting.

— Michael

 

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