I’ve Got 99 Problems, and Insurance is All of Them
By: Gina Romero, LICSW, LCSW
If you've ever stared at a bill from your therapist's office and thought, "Wait, I have insurance–why the hell am I paying this much?,” you're not alone. We often have the same thought when we receive an EOB from a client’s insurance plan.
Insurance is confusing on purpose, and mental health benefits can be some of the most confusing of all. At Wandering Pine Wellness, our Admin Team verifies benefits for each client before their first session, with the goal of providing clarity around costs. And even then, insurance will come back and tell prospective clients something completely different than they told the provider.
I get phone calls or emails from confused clients every week. Someone comes in expecting their session to be fully covered, and instead they get a bill that makes them want to cancel therapy altogether, which is exactly the kind of barrier that keeps people from getting support they need. I hope that this blog will help you better understand your insurance coverage in plain language, so you can walk into this with your eyes open instead of feeling blindsided.
Insurance is Frustrating
You pay a premium every month. Insurance told your provider that your sessions are “covered at 100%.” Insurance told your therapist’s office the same thing.
You complete your first session. You still get a bill.
You call your insurance company and get transferred four times. You finally get an answer, and it turns out that “covered at 100% doesn’t include the copay.”
You scream, and you think about rare-quitting therapy. You therapist’s office is told [by insurance] to charge you $40 for the session. We scream too.
None of this is your fault, and none of it is really ours either–we're all just trying to navigate a system that was built to prioritize profits (not patient care).
My goal with this post is to hand you the vocabulary and the questions you need so you're never caught off guard again.
The Terms You Keep Hearing (And What They Mean)
Deductible: Think of your deductible as insurance's cover charge. If your deductible is $2,000, insurance is standing at the door with its arms crossed saying "we're not paying for a single thing until you hand us $2,000 first."
You show up to therapy ready to heal. Insurance says "not yet, bestie." You pay full price for every session until you've hit that number. Then, and only then, does insurance start acting like it knows you.
Copay: The copay is the "gotcha" fee. This is the flat amount– say, $30 or $40, that insurance waits to spring on you after it's already told you and your therapist's office that your sessions are "covered at 100%." Covered at 100%, except for this part, which we conveniently forgot to mention until you got the bill.
Coinsurance: Coinsurance is insurance's version of "let's split it," except they get to pick the split and it's never 50/50 in your favor. If you have 20% coinsurance, you're paying 20% of the bill and insurance covers the other 80%... but only after your deductible is met, and only until you hit your out-of-pocket max. It's like Venmo-requesting your friend for dinner, except the friend is a Fortune 500 company and you're the one who has to keep checking the app to see if they paid.
Patient Responsibility: This is the line on your bill where all of the above gets added up and turned into an actual number you owe. Deductible plus copay plus coinsurance, minus your first born, equals "patient responsibility."
Explanation of Benefits (EOB): The EOB is the mysterious document insurance sends you that looks like a bill, feels like a bill, gives you the same heart-drop feeling as a bill... and is legally not a bill. It's just insurance's play-by-play of what happened behind the scenes: what we charged, what they "allowed" (a whole separate made-up number, which is, for the record, not even close to your therapist’s full fee), what they paid, and what's left for you. Read it. It is, annoyingly, the most honest document in this entire process.
The Codes You'll See on Your Bill
Every therapy session gets billed to insurance using a CPT code. This is a standardized number that tells the insurance company what kind of service was provided. Here are the three you'll see most often from our office:
90837: Individual psychotherapy, 60 minutes This is our most commonly billed code. It covers a standard, full-length individual therapy session. 60 minutes is sort of misleading, because this code covers anything from 53 minutes to several hours minutes. They pay us (the provider) the same rate, whether we spent 53 minutes or two hours in a session with you.
90834: Individual psychotherapy, 45 minutes A slightly shorter individual session. This code covers anything from 38-52 minutes.
90847: Family or couples psychotherapy, with patient present This code is used for family sessions where one person is the the “identified client,” and that person is present in the room. Anything from 38-52 minutes is billed using this code.
Special note: This code is also used for family our couples therapy where the relationship is the patient (not just one person), but that’s a discussion for another blog post.
Insurance companies can reimburse these codes differently, and your deductible, copay, or coinsurance may look different depending on which code was billed. If your cost seems to have changed from one session to the next, checking which code was used is a good place to start.
What Questions Should I ask My Insurance Company Before My First Therapy Session?
Calling your insurance company can feel like its own form of exposure therapy. Here's a script to make it faster and more useful. Ask specifically about outpatient mental health / behavioral health benefits, and have your plan ID ready.
"Do I have a deductible for outpatient mental health services, and how much of it have I met this year?"
"What is my copay or coinsurance for outpatient mental health visits, once my deductible is met?"
"Is [provider name / practice name / NPI number] in-network with my plan?"
"What is my out-of-pocket maximum, and how much have I met so far this year?"
"Is there a limit on the number of therapy sessions covered per year?"
"Do I need a referral or prior authorization for therapy?"
"What is my cost for CPT code 90837 (or 90834, if applicable)?"
Write down the reference number and name of the representative you speak with. Insurance companies make mistakes, and having a record protects you if a claim comes back different than what you were told.
It Shouldn’t Be This Complicated, but Alas, Here We Are
Insurance shouldn't be the reason you avoid getting support. Our team is happy to help you understand your specific benefits before you get started, and to talk through what your costs might realistically look like.
Whether you’re in Las Vegas near our Summerlin office, in Reno, Pahrump, Boulder City, or anywhere in between, Wandering Pine Wellness is here to help!
About the Author:
Gina Romero (LCSW, LICSW) is the Founder and Co-Owner of Wandering Pine Wellness. Gina opened WPW’s original location in Eastern Washington in 2022, and currently works out of our Las Vegas office. She is passionate about community education, and has taught insurance credentialing classes to therapists in her community.
