Insurance, coverage, and what a visit costs

When you request an appointment, we contact your plan and check the things that decide what you actually pay: whether the practice is in network for your specific plan, whether a referral or prior authorization is needed, what your copay is, and whether your deductible has been met.

You get that back before the appointment, in plain numbers. Nobody should have to guess what a visit costs and then find out six weeks later.

Three numbers determine your share of a visit, and plans use them differently:

• Copay: a flat amount per visit, due at the time of the appointment.
• Deductible: what you pay yourself before the plan starts contributing. Early in the calendar year, a "covered" visit can still be billed at the full contracted rate until the deductible is met.
• Coinsurance: a percentage of the visit you pay after the deductible is met.

Plans also distinguish behavioral health from general medical benefits, and the two can have different copays and deductibles on the same card. That is one of the things we check.

Most plans let you see a psychiatric provider without a referral. Some HMO plans and TRICARE Prime require one from your primary care provider or PCM, and a visit without it can be denied, so it is worth confirming rather than assuming.

Prior authorization is a separate thing, and it applies to specific treatments rather than to ordinary visits. TMS is the main one: carriers generally require documented trials of medication before approving it. We handle that paperwork, including gathering the treatment history from previous prescribers.

Nearly every plan now covers behavioral-health telehealth at the same rate as an in-office visit, TRICARE, Medicaid, and Medicare included. A handful of plans still apply different cost-sharing to video visits, which is one of the details we check when we verify your benefits.

You do not need insurance to be seen here. Self-pay rates are quoted before you book, never after the visit, and paying directly is sometimes the simpler option for people with a high deductible or a plan the practice is out of network for.

Self-pay also keeps a diagnosis out of an insurance record, which some patients care about a great deal and others not at all. It is a reasonable thing to choose deliberately.

If you are uninsured or choosing not to use your insurance, federal law entitles you to a Good Faith Estimate of what your care will cost, in writing, before you are seen. You will be given one; you do not have to ask.

The estimate covers the expected cost of your evaluation and of ongoing visits. If a final bill exceeds the estimate by $400 or more, federal law gives you the right to dispute it. Ask for a copy any time your treatment plan changes and you want the numbers refreshed.

It happens, and it is not the end of the conversation. Many plans include out-of-network behavioral health benefits that reimburse a share of what you pay. In that case we provide an itemized receipt (a superbill) with everything your plan needs to process the claim.

Tell us what plan you have and we will tell you which situation you are in before you commit to anything.