We get lots of questions from healthcare providers wanting to know how to handle patients/client deductibles.
If you are in network with an insurance company, this is how deductibles work—at least for behavioral health.
Scenario ONE:
Client A has Blue Cross Blue Shield (BCBS) with a deductible of $500, and plan with a $15 co-pay. He sees Dr. Smith for counseling, who is a licensed psychologist. BCBS’s rates for a licensed psychologist is $161.00 (hypothetical) for an initial assessment and $90.81 (hypothetical) for ongoing individual therapy sessions.
If this client has a deductible, this is what the client / insurance pays:
- 1st visit: $161 paid by client, zero paid by BCBS (remaining deductible $339)
- 2nd visit: $90.81 paid by client, zero paid by BCBS (remaining deductible $248.19)
- 3rd visit: $90.81 paid by client, zero paid by BCBS (remaining deductible $157.38)
- 4th visit: $90.81 paid by client, zero paid by BCBS (remaining deductible $66.57)
- 5th visit: $66.57 + $15 paid by client, $9.24 paid by BCBS (no deductible remains)
- 6th visit: $15 paid by client, $75.81 Paid by BCBS
- And so on …
Note: you cannot charge the client more than what insurance would have traditionally paid. Even if your “cash” rate is higher, you need to charge the client the lower, insurance approved, rate.
Scenario TWO:
Client B has no deductible, just a $25 copay. The client also sees Dr. Smith.
- 1st visit: $25 paid by client, $136.00 paid by BCBS
- 2nd visit: $25 paid by client, $65.81 paid by BCBS
- And so on …
Again, BCBS’s “allowable rate” for psychologists is $161 for initial diagnostic evaluation and $90.81 for mental health counseling / psychotherapy sessions.
Summary:
When a healthcare provider signs a contract with an insurance company he/she agrees to their rates. Hence, when a client has a deductible the provider can only charge the client the same insurance allowed rates, not higher self-pay rates.
Hope this is helpful and not just confusing 🙂
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Anthony Centore
Is it okay to charge less than what the insurance company allows.
Thank you
Tamera Mensink
Good question. If you’re networked with an insurance company, and if you read through your insurance contacts, it likely (very likely) states that the insurance company you’re contracted with, is to receive your lowest rate.
Is there any negative consequence for billing higher than the contracted rate.
Doesn’t the insurance company adjust for the difference in the EOB?
Generally, insurance will just pay their contracted rate regardless of how much you charge. It’s normal for clinicians to bill higher, as they know if they happen to bill lower then insurance companies may pay less than the contracted rate.