FAQs and Additional Behavioral Health Information

Additional Resources for Behavioral Health Information
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Answers to Frequently Asked Questions

 

 

What is A Prior Authorization?

Prior authorization is an extra step that some insurance companies require before they determine whether they will cover a particular medication based on the patient’s selected insurance plan.  There are a number of reasons that insurance companies require prior authorization, including age, medical necessity, or the availability of a different, “preferred” medication or generic alternative in the same drug class.

 

           

The process to obtain prior authorization varies from one insurer to another, but it typically involves completion of a prior authorization form; this includes a full review of the patient’s chart- including diagnosis, history of failed medications, current symptoms, and a detailed explanation of the physician’s rationale for choosing a particular medication over another.  After the form is submitted, the insurance company will review the request and within approximately one week they will notify our office of their decision to approve or deny the medication.  In the event that the medication is denied, the patient may request that the physician file an additional appeal for coverage.  In some cases, it may take up to 30 days to receive a determination on an appeal.

 

         

If the medication is ultimately denied, the patient can still pick up the medication if they are willing to pay for it out-of-pocket.  Alternatively, the insurance company may require the patient to go through a “step therapy” process, wherein the patient must see unsuccessful results from preferred medications before the insurance will consider covering a different medication. 

 

If your insurance company has denied a medication that your doctor prescribed, or if you would like to obtain a list of your plan's "preferred" or covered medications before an appointment, contact your Plan Administrator and ask the following questions:

 

  1. What medications are covered under the patient’s plan?  Specify the class of drugs you are asking about (e.g.,  antidepressants, antipsychotics, anxiolytics, psychostimulants, mood stabilizers, etc.)

  2. Are there any excluded medications under the plan? Insurance will not cover excluded medications, no matter how much paperwork we complete.

  3. What other medications must the patient try before the prescribed medication will be approved? Often, the patient must try and fail certain alternatives before a selected medication will be approved- this is called "step-therapy."

  4. Is the generic alternative of the prescribed medication covered?

 

What is Out of Network Benefits?

Out of Network Benefits

An out-of-network provider is one which has not contracted with your insurance company for reimbursement at a negotiated rate.  This means that the provider is not part of your “preferred” network and your insurance may not cover the costs of treatment, or they may cover them at a reduced rate.

 

Although many of the providers at MLBG are out of network with most commercial insurance plans, we will be happy to file claims on your behalf to your out-of-network benefits as a courtesy.  You will be asked to pay in full at each appointment and we will submit the claim to your insurance company so that if there is any reimbursement, it will go directly to you and not through our billing office.  We understand that going out-of-network may be difficult for some patients, and if you are unable to do so, we recommend contacting your insurance company for a list of in-network physicians available in your area.

 

If you would like to understand more about the out-of-network benefits available through your specific insurance plan, we encourage you to contact the customer service department of your insurance company.  Here are a few key words and questions for you to ask:

  • Ask the representative about your Out-of-Network Benefits for Outpatient Mental Health in an Office setting. 

  • You will want to find out what the Out-of-Network Deductible is; this is typically separate from your in-network deductible. Upon satisfying that deductible, you would then be responsible for a Co-pay or Co-Insurance amount.  You will still pay in full with our office, but once the OON Deductible is met, your insurance may start to reimburse you directly for the amount they would cover. 

  • Find out if there is an Out-of-Pocket Maximum; once this amount is met, the insurance may begin to reimburse you in full. 

  • You should also inquire as to whether Prior Authorization is required to see an OON provider, and also if there is a Visit Limit per calendar year.

 

It may seem overwhelming to navigate the complicated waters of insurance benefits, but once you have a basic understanding of what the benefits are and how they apply to you, you can get the maximum benefits from your plan.  Knowing what these terms mean for you will help you make more informed decisions as you choose plans in the future.

 

 

 

What is the Difference between Psychiatry and Psychology?

 

A Psychiatrist is a Medical Doctor with a specialty in mental health.  These physicians are certified to assess and diagnose patients and authorized to prescribe medications to treat those diagnoses.  Their work tends to be more clinical—they are trained to conduct physical exams, order and interpret laboratory tests, and monitor patients to make sure prescribed medications are having the desired effect. 

 

The first appointment with a psychiatrist at MLBG is a detailed 60- 90-minute evaluation which explores the patient’s medical and mental health history, as well as social, behavioral, academic and familial factors.  Upon determination of a diagnosis, the physician and patient will work together to coordinate a treatment plan including medication management and, if necessary, a recommendation for additional therapies and accommodations. 

 

Following the initial evaluation, patients are scheduled for a follow-up appointment to assess the effectiveness of the treatment plan and medications.  As medications are adjusted, patients are required to follow-up within 3-4 weeks to evaluate his or her progress.  Once the patient is stable on his or her current medication regimen, follow-up appointments are typically spaced 2-3 months apart.  Patients must be seen every 90 days in order to continue with treatment (per DEA and FDA regulations).

 

A Clinical Psychologist/ Therapist is a licensed professional who is qualified to offer counseling to patients.  They often do this by integrating science, theory and clinical knowledge in order to assist the patient in understanding and relieving psychologically-based distress or dysfunction, with the aim of promoting behavioral and subjective well-being. 

 

There are many kinds of therapists; at MLBG we have PhD and PsyD psychologists, as well as LCSWs (Licensed Clinical Social Worker) and LMHC (Licensed Mental Health Counselors).  Each of these professionals are trained to work with patients through a variety of methods of psychotherapy and counseling, and typically there are specific areas in which each provider specializes.

 

We also conduct psychological and academic testing in our office, which is separate from the above categories.  Please see below for a detailed description of the varieties of testing we offer. 

 

Child and Adult Psychological Testing

ADHD (Attention-Deficit/Hyperactivity Disorder)

Learning Disabilities

Gifted Testing

Emotional Issues

Developmental Delays/Autism Spectrum Disorders

 

Letter Requests and Forms

 

In the event you should require a letter, form, or other documentation from your provider, please fill out the appropriate forms linked below, and then contact the office staff to discuss your request.  In order to ensure that we have all necessary information to write the most effective letter on your behalf, we have provided a “Letter Request Form” for your convenience.   It is imperative that you complete this form in its entirety with as much detail as you can provide so that the provider can reference the information needed at the time he or she is writing the letter.  We also ask that you fill out the accompanying “Release of Information Consent Form,” which gives the provider your explicit authorization to release information to the recipient of the letter.  We cannot proceed with any letter request until we have received both forms.

 

We understand that letter requests are of considerable value to our patients and we do not take them lightly.  Your provider will need additional time to review your file before writing the letter, so please plan accordingly and allow 3- 4 weeks between the time of your request and the deadline by which you need to receive the final draft.  Please understand that there is a fee for writing letters and filling out forms; we will be happy to give you an estimated cost of the letter or form once the requested documents have been received and reviewed by the provider.

 

Additional Fees

            Prior Authorizations

            Prescription Refills

            No Shows/ Missed Appointments

            Late Cancellations

            Letters and Forms

Cancellation and No-Show Policy

A specific block of time has been reserved for your appointment, so if you need to cancel or reschedule and appointment, please give 24 business hours of advanced notice.  Our business hours are from Monday- Thursday 8:00-4:30 p.m. and Friday from 8:00-12:00 (noon) and do not include the weekends or holiday's.  To properly insure that a Late Cancellation or No Show fee isn't applied to you, please contact our office during our normal business hours. 

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