Insurance: How to Use Your Out-of-Network Benefits

Concierge Care: The Benefits of Going "Out-of-Network"

We are confident that your experience with us will be like no other. Why is this? Because at Kentlands Psychotherapy, we consistently out-delivering our peers on Three Critical Components of your experience:

* The extraordinary nature of your psychotherapy experience. Our providers are the best in the area! (see our credentials and clients' testimonials)

* The outstanding customer service delivered by Petra, our Director of Administrative Hospitality, and our 21st-century user-friendly secure communication and scheduling platforms. Ask your therapist about the option of telemedicine appointments when you're out of town on business with our very user-friendly encrypted App.

* The exceptional ambiance and amenities throughout our care environment.

See our Testimonials page for details

Insurance

We do not accept insurance. We have chosen this intentionally so our therapists have more control over your treatment. Many insurance companies limit the number of sessions with in-network providers, do chart reviews of in-network providers (compromising your privacy), do not cover some treatments our clients are seeking, such as sexual functioning concerns when billed directly, and most do not cover couples therapy when in-network. Insurance companies also reimburse providers at significantly lower rates than the local market, which results in many clinicians with exceptional skills and advanced post-degree training leaving their panels.

By being out-of-network, we can recruit exceptional clinicians committed to providing you with the outstanding treatment you are asking for and deserve without the insurance company dictating everything they do. With this, you can also feel more comfortable that your private information is kept entirely confidential and away from your insurance company. If you would like to, you are welcome to submit your receipts to your insurance carrier for possible out-of-network reimbursement. Some insurance companies will reimburse our clients a portion of the costs for each session. At the end of each month, we will supply you with an itemized medical receipt, called a Superbill, which you can submit along with your claim form to your health insurance provider for reimbursement. There is no guarantee that your insurance provider will accept a portion of the total cost of services. Contact your health insurance company to see if they accept out-of-network provider superbill receipts for claim reimbursement.

To use your insurance to help cover your costs of care, you will need to plan on submitting your paid receipts to your insurance company for partial reimbursement. This is because we are not in-network with any insurance companies. This means that we do not take co-pays for services and balance bill insurance carriers.

As licensed mental health professionals, your health insurance will likely reimburse our out-of-network services in full or in part.

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You can pay for your appointments with cash, check, or credit/debit card. Additionally, you may use your employee benefit plan's HSA/FSA card (using pretax dollars) as our credit card processing merchant account is registered as "medical."

We will provide you with paid receipts, including CPT treatment and diagnostic codes, that you can submit to your insurance company for reimbursement. Please ask your therapist for details and advice on navigating this process. Although we cannot submit this paperwork on your behalf, please let us know if this process is new to you. We are here to help!

You can learn more about your insurance benefits by asking your insurance carrier's customer service representative the following questions:

Do I have mental health benefits?
What is my annual deductible, and has it been met? How much is remaining? Does it restart at the end of the calendar year or another time? Do we meet the deductible individually or as a family unit?
Is there a limit to the number of sessions my plan will reimbursed for in a calendar year? Or a spending cap?
Does my plan allow for the use of out-of-network providers? (Our providers are Out of Network at this location; Kentlands Psychotherapy does not have empaneled providers.)
What is the cost-sharing component/split?
What do you consider 'reasonable and customary' R&C for a CPT code of 90834 (the insurance company's idea of a standard fee for a 45-minute follow-up psychotherapy appointment), and what percentage do you reimburse for that? So, for example, if they consider $100 R&C and reimburse 80% of that amount, they should cut you a check for $80 after each of your $175 appointments. On the other hand, if they considered $200 R&C, they would reimburse 80% of the full appt fee (for example) of $175; hence, you could expect a check back for $140. (i.e., 80% of $175.00)
Is approval required from my primary care physician?
Are there any standardized forms I will need to submit for reimbursement? Where do I find these forms on your (insurance) company's website?

Bill Payment

Payment is due at the time of service unless prior arrangements have been made with your provider. We accept all major credit cards, cash, and personal checks. We will provide a medical receipt called a Superbill at the end of every month for you to submit to your insurer for reimbursement, generally on the Monday following your appointment.

All questions regarding your account should be directed to our Director of Hospitality, Petra Desmond, at PDesmond@Kentlandspsychotherapy.com.

24-Hour Cancellation Policy

When canceling or rescheduling appointments with more than 24 hours' notice, please use the patient portal. If you need assistance with this technology, please call Petra Desmond at (240) 252-3349.

If you do not attend your scheduled appointment and you have not notified your therapist at least 24 hours in advance, you will be charged the full fee for the appointment as booked. Please call us as soon as possible if you have trouble keeping your appointment. Please text or call your therapist first if you need to cancel on short notice. You can also call the office, but know that this should not be the primary method for notifying your therapist, as these main phone numbers may have a delay in picking up messages and relaying them to your provider. In emergency cases, exceptions to the 24-hour policy can be made.

Other Policies

You will learn more about record-keeping, privacy, and other billing policies in the online paperwork you complete before your initial consultation. If you have any questions or concerns about these forms, please bring them to the attention of your therapist before or during your first appointment.

Need to reschedule for illness? Click her for suggestions on communicating with your therapist about rescheduling for illness.

Inclement Weather? Click here for our inclement weather (snow) policy.

Do You Have Medicare?

All of the providers at Kentlands Psychotherapy have opted out of participating in Medicare at the Kentlands Psychotherapy location (some may be participating at an alternate location not affiliated with Kentlands Psychotherapy). To see a Kentlands Psychotherapy provider, clients must complete a waiver form acknowledging that they understand they are forfeiting the use of their primary MEDICARE and secondary gap insurance in order to receive care with one of our providers. If you need to use your Medicare and secondary gap insurance benefits for your mental health care, we recommend you speak with your primary care physician to ask for suggested referrals for in-network Medicare providers.

Do You Have Medicaid?

As of January 3, 2024, in the state of Maryland, it is generally illegal for healthcare providers to accept private pay or out-of-pocket payments from a Medicaid member for services covered by Medicaid. This law is in place to prevent Medicaid members from being taken advantage of by providers. The expectation is for providers to enroll in Medicaid, and this regulation helps protect Medicaid members while encouraging providers to participate in the Medicaid program.

Additionally, as of July 1, 2024, Maryland Medicaid will deny all pharmacy claims where the prescriber is not enrolled as a Medicaid provider.

None of our clinical staff participate in the Maryland Medicaid Program.

Do You Have Tricare (Prime or Select)?

TRICARE Prime is an HMO-like program. Patients must see in-network healthcare providers to have their care covered. In some cases, TRICARE will make single-case agreements with medical providers to pay a worker who is not in-network their in-network rate to fill a need gap when no in-network providers can be identified to meet a patient's need. Kentlands Psychotherapy does NOT make single-case agreements with TRICARE.

TRICARE Select is more of a PPO program. Patients have more freedom to see healthcare providers of their choice. Unlike with most PPOs, with TRICARE, those out-of-network providers must have registered with TRICARE as non-participating out-of-network providers before TRICARE will reimburse the beneficiary for their care. A FEW, but NOT ALL, of our Kentlands Psychotherapy providers have completed this registration process.

WARNING: The TRICARE East website shows outdated and incorrect data about providers with this status. Please don't trust the website. Call us AND confirm with TRICARE directly that the information on their TRICARE website is correct before trusting that your care with any specific provider will be eligible for reimbursement.

We wish for our TRICARE clients that this process was simpler, but unfortunately, it is not. Please call us if you have questions about using your TRICARE Select benefits to receive care at Kentlands Psychotherapy.

Notification of Federal Protections against Surprise Billing: No Surprises Act/ Good Faith Estimates

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, medical equipment such as Alpha Stims, and hospital fees. Your health care provider will provide you a Good Faith Estimate in writing prior to your medical service or item. You can also ask your healthcare provider and any other provider you choose (to work with) for a Good Faith Estimate during scheduling. If you receive a bill that is substantially higher than estimated on (more than $400) your Good Faith Estimate, you can dispute the bill. It is a good idea to save a copy of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises

Notification of Federal Protections against Surprise Billing for Out-of-Network Clients

Getting care from this provider or facility could cost you more as we are out-of-network:

If you have insurance and choose to proceed to work with us, getting care from this provider or facility could cost you more than if you went to an in-network provider.

Know that if your insurance plan covers the item or service you are getting, federal law protects you from higher bills when you get emergency care from out-of-network providers and facilities or when an out-of-network provider treats you at an in-network hospital or ambulatory surgical center without your knowledge or consent.

Ask your healthcare provider or patient advocate if you need help knowing if these protections apply to you.

According to federal regulations, a waiver can be signed to pay the full fees, which may be more than your in-network benefits, which may mean you have:

Given up your protections under the law. You may owe the full costs billed for items and services received. Your health plan might not count any of the amount you pay toward your deductible and out-of-pocket limit. Contact your health plan for more information (regarding your out-of-network benefits).

You should not sign any waivers, if you did not have a choice of providers when receiving care. For example, a doctor was assigned to you with no opportunity to make a change (or without choice). Before deciding whether to sign a waiver, you can contact your health plan to find an in-network provider or facility. If there isn't one, your health plan might work out an agreement with a provider or facility.

Your Rights and Protections Against Surprise Medical Bills

When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.

What is "balance billing" (sometimes called "surprise billing")?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a healthcare facility that isn't in your health plan's network.

"Out-of-network" describes providers and facilities that haven't signed a contract with your health plan. Keep in mind that out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay (in-network rate) and the full amount charged (private fee) for a service. This is called "balance billing." This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.

"Surprise billing" is an unexpected balance bill. This can happen when you can't control who is involved in your care--like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.

You are protected from balance billing for Emergency services

If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments, deductible, and coinsurance). You can't be balance billed for these emergency services. This includes services you may get after you're in stable condition unless you give written consent and give up your protections not to be balance filed for these post-stabilization services.

Certain services at an in-network hospital or ambulatory surgical center

When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most these providers may bill you is your plan's in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can't balance bill you and may not ask you to give up your protections not to be balance billed.

If you get other services at these in-network facilities, out-of-network providers can't balance bill you, unless you give written consent and give up your protections.

You are never required to give up your protections from balance billing. Additionally, you also aren't required to get out-of-network care. Remember, you can choose a provider or facility in your plan's network.

When balance billing isn't allowed, you also have the following protections:

You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly. Your health plan generally must: cover emergency services without requiring you to get approval for services in advance (prior authorization). Cover emergency services by out-of-network providers. Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits. Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.

For more information about your rights under federal law, visit: https://www.cms.gov/nosurprises/consumer-protections/Payment-disagreements