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Paying For Eating Disorder Treatment FAQ

Some Frequently Asked Questions:

 

(1) Is the Kartini Clinic contracted with my insurance company?

Kartini Clinic has and will continue to make every effort to contract with those insurance carriers who provide quality medical and mental health benefits and who support the medically-focused, family-based treatment model used at Kartini Clinic. Even if we are not contracted with your insurer we can work with you to secure a Single Case Agreement (SCA). SCAs can often cover some or all of treatment costs.

By the time you read this you may have made an appointment already and know if your insurer is contracted with the Kartini Clinic. If you aren’t sure whether your insurer is contracted, call 503 249 8851 and ask for our business office.

(2) If my insurance is contracted, what are the medical and mental health benefits under my plan?

We will contact your insurance company and request a summary of your benefits. We will provide you with a written summary of the information given to us by your insurer at your first appointment. We always recommend you verify any information given to you; insurance companies have been known to give inaccurate information to providers. As you ultimately will be responsible for any outstanding balances, it is essential you satisfy yourself that all benefit information is accurate and up-to-date.

Authorization for Treatment

Our clinical staff will obtain any treatment authorization(s) required under your insurance policy, provided your insurance company has given us accurate information regarding any authorization requirements.

Payment

As a patient of a contracted provider you will be responsible only for your copays, coinsurance and patient responsibility balances as determined under your policy. Your insurance company will reimburse Kartini Clinic directly, in accordance with the benefits of your insurance policy. Kartini Clinic will bill you directly for these balances.

Claims

Kartini Clinic will file all of your claims directly to your insurance company. You should receive from your insurance company an Explanation of Benefits (EOB) detailing any payments made directly to us on your behalf. If you do not receive EOBs within 30 days of receiving treatment, please contact your insurance carrier immediately. Insurance carriers are required by Oregon law to furnish you with information within 30 calendar days of your appointment.

(3) If my insurance company is not contracted with Kartini Clinic, what are my out-of-network medical and mental health benefits?

Unfortunately it is not possible to contract with every insurance carrier. If your carrier is not contracted with the Clinic, you, as the member, are responsible for complying with your insurance carrier’s policies. This begins with an authorization for treatment (see below).

If your insurance carrier is not contracted with Kartini Clinic, you may still be able to gain partial reimbursement for any treatment costs. Many policies provide out-of-network benefits. Ask your insurance carrier if you have such benefits.

Even if you are informed no such benefit exists under your policy, you may still request to have treatment at Kartini Clinic covered. Many insurance plans provide for reimbursement if you can prove that no similar treatment program exists in your area. Your primary care physician can help you make this case to your insurance carrier. Please be advised that Kartini Clinic can furnish you and/or your doctor with information about our program, but we cannot intervene to write letters, call medical directors, etc. on your behalf. It is up to you and your doctor to secure approval for treatment at the Clinic.

Authorization for Treatment

Regardless of your insurance status, our clinical staff will attempt to obtain any treatment authorization(s) required under your insurance policy, provided your insurance company has given us accurate information regarding any such requirements. We will inform you of any denials in authorization.

Payment

If your insurer is not contracted, you will be asked to pay at the time of your visit. Reimbursements from your insurer must go directly to you rather that to the Clinic. Kartini Clinic cannot accept reimbursement from insurance companies for services already paid by you. Such payments are often made to Kartini Clinic in error and regrettably must to be returned to your insurance company.

Please note that refusal to pay at the time of your visit may result in rescheduling of your appointment.

Claims

We will file all necessary claims directly to your insurance company unless you instruct us otherwise, even if we are not contracted with your insurer. We provide this service because we understand how difficult it can be to manage complex paperwork while simultaneously struggling to care for a sick child. However, we cannot guarantee correct processing or payment of your claims by your insurance carrier. We do our utmost to follow industry standard guidelines for claims as established by the Federal government, but each insurer is different and some claims can be delayed for extensive periods of time.

In the case of claim denials, the balance of any visit becomes your responsibility. As an out-of-network provider, the Kartini Clinic is entitled to payment even if your insurance carrier refuses to cover the services provided to you. It is therefore essential that you monitor the progress of reimbursement by your insurance carrier. If a claim is more than 30 days old, call your insurance carrier and ask about the status of your claim. Under Oregon insurance regulations, insurance carriers must notify you as to the status of your claim within 30 calendar days of receiving it. Accept no excuses! If the insurance representative is not helpful, ask for a supervisor. Don't hesitate to be persistent. In our experience persistence is usually rewarded.

(4) What is the difference between medical and mental health benefits, and how can this affect my treatment at Kartini Clinic?

All insurance policies are divided into two parts: medical and mental health benefits. Most policies have different sets of benefits for medical and mental health, with mental health benefits sometimes being limited to a certain number of visits per calendar year or 24-month period.

There are three different types of benefits that are usually accessed for treatment at Kartini. They are:

  1. Outpatient Medical
  2. Outpatient Mental Health
  3. Mental Health Residential / Day Treatment (DTU) / Intensive Outpatient (IOP)

Outpatient Medical benefits:

  1. Inpatient rounds with a doctor (Even with a child in hospital, Kartini services are considered outpatient services, since we are NOT a hospital but simply providing service to a patient who is in the hospital.)
  2. Outpatient medical exams with MD (often referred to by insurance carriers as “office visits”)

Outpatient Mental Health:

These benefits are usually limited to a set number of visits by the insurance company and used for three services:

  1. Family Therapy
  2. Group Therapy 
  3. Individual Therapy
  4. Initial Psychiatric Evaluations

Mental Health Residential / Partial Hospitalization / Intensive Outpatient:

These benefits are usually strictly limited and used for:

  1. Day Treatment (treatment of at least 4 hours or more per day)
  2. Intensive Outpatient Program (treatment of less than 4 hours per day)

(5) What is mental health "parity" and how does it affect me?

The Oregon legislature passed a law requiring health insurance plans to provide mental health benefits on par with medical benefits under the same plan. This statute is referred to as the mental health "parity" law. Under this law you may be eligible for extended mental health benefits. You should contact your insurance company for answers about your specific benefit plan.

(6) What do I do when I'm not getting what I need from my insurance company?

The name of the game is persistence. Insurance companies are far more responsive if they know you are going to advocate for your rights and those of your child. You are the paying member, and at the end of the day you are the only person who can ensure that you get what you are entitled to. Most importantly, you are ultimately responsible for payment.

If you have any questions, call your insurance carrier right away, and don’t get off the phone until you are satisfied your question has been answered. Here are a few tips when talking to insurance companies:

Tip #1: when talking to your insurer, be sure always to get a name and, if possible, a direct line or extension number of the person you are speaking with. Take notes, and don’t be afraid to ask for a supervisor if you are not getting the answers you need. Remember, you have paid for this insurance and the company owes it to you to answer your questions thoroughly and promptly.

Tip #2: we recommend that every Kartini Clinic parent and/or patient seek a care manager. A care manager is a single point of contact between you and your insurer. Such a person will know your name and the particular requirements of your case. A care manager will be able to help with authorizations for treatment as well as with claims that are either denied or paid incorrectly.

If asked why you want a care manager, you may inform them that we recommended you seek one because of the complicated nature of eating disorder treatment, particularly the transition from inpatient to day treatment and eventually outpatient. Each step in the process usually accesses separate benefits within your plan. Most insurers do not have enough trained staff to ensure your claims are looked at by someone who understands this. And be prepared for them to say no, but keep asking. In the end, again, your persistence is likely to pay off.

Tip #3: when insurance companies say they have "paid" a claim, this does not correspond to the customary meaning of the phrase. What they often mean is the claim has been "released" for payment and will take another two weeks (or more) to arrive at its intended destination. To determine whether a check has actually been cut, ask for a check or voucher number. If they can't give you one, it means they haven't paid the claim yet. It is also useful to ask where the check was sent. Unfortunately insurance companies often send payments to providers' offices when they should be sent to you (and occasionally vice versa), and that can result in further delays as such checks have to be returned to the insurance company in order to be reissued. Kartini Clinic will not sign over insurance checks to anyone.