New Year Benefits: What You and Your Clients Can Expect




The COVID-19 pandemic has altered the way that health insurance operates, but has brought about some exciting innovations in the mental health industry. Every provider that was taking insurance in the first part of the year in 2020 remembers when most insurance companies started to waive deductibles, copays, and coinsurance for most mental and behavioral health benefit plans. That particular move provided needed financial relief to Americans in a time of need. However, there is still not enough support for the damage that the COVID-19 pandemic wrought on the American public.


According to this article nearly 29% of Americans lost health insurance coverage in 2020 because of financial concerns. The same survey asked more than 2,000 consumers about their recent enrollment for 2021 and found that 45% of health care marketplace users were surprised by the high costs of their new policies. This has led to a number of key findings that are important to discuss as you go into the new year with clients that have likely had big insurance policy changes.


According to the previously cited article here are some key findings that are important to look at and analyze for your practice as you move forward in 2021:


First, Gen Zers and those who were laid off were particularly impacted by the pandemic in relation to their health insurance coverage. Half of Gen Zers lost their coverage and still remain without health insurance. This could mean that if your practice was made up of Gen Z clients, then you are likely struggling to return to a normal claim-run rate that you enjoyed pre-pandemic.


Second, the main reason why many lost their coverage and remain uncovered is cost-driven. Of the respondents that said they lost coverage, 42% of those people said they don't have enough money to afford premiums or the deductible, while 31% said they have other expenses they need to prioritize.


Third, while some consumers turned to the marketplace for coverage, what they found posed significant challenges for them. Nearly 64% of respondents who have purchased insurance through the marketplace at some point encountered issues and confusion about the policies. This included differing information about the plan or frequent updates to policies that it was difficult to keep up with the changes.


Fourth, consumers purchasing plans through the marketplace found that they were surprised by the cost increase in the insurance policies. 45% of people were surprised by the increase in health insurance, however, younger generations were most likely to spend more on health insurance.


Fifth, consumers tend to be divided about the number of choices that they are given. 38% of consumers felt there are not enough choices on the marketplace, 33% feel there are too many choices, 59% feel there are enough choices of plans, and 29% would prefer a single option of health insurance.


If you were to ask the general public, "Did you lose health insurance in 2020?" here is how the responses would look in pictorial form:






Because of the problems that most people faced with their health insurance here are some of the problems that you might be facing going into the new year with insurance coverage:


  1. Clients are unable to accurately describe their insurance benefits

  2. Clients might think they have different benefits than what they do

  3. Clients may not understand that they owe a deductible before the insurance begins to pay

  4. Clients may have a different understanding of what their deductible is

  5. Clients may believe they owe a copay for services instead of a deductible or coinsurance

  6. Clients may have anxiety about which provider to choose based on the insurance plan that they bought on the marketplace

  7. Clients may not understand that some providers may be credentialed with a different plan than what they have

This is not nearly a comprehensive list of problems that providers are likely to run into over the coming weeks and months, but it is likely that you will run into at least one or two of these concerns.


The good news is that there are ways to avoid or even alleviate the concerns that your clients have about using their insurance or how the process looks. The first thing to consider is that your client may not have an idea of how insurance works, let alone how their insurance works. Here are some things that you, your biller, or your front office admin can do to create the best client experience in the event that your client shows any of the concerns listed above.



Concerns and Solutions


Concern #1: Clients are unable to accurately describe their insurance benefits


Solutions to #1: The first thing to do is to reassure your client that health insurance can be difficult to understand for everyone. Unfortunately, it is normal to be confused by health insurance. Here is a helpful way to breakdown how insurance works from a cost perspective since most of the research shows that cost is the #1 pain point for clients right now.


If you are in-network with the clients insurance they can expect one of three scenarios to occur in the event that a claim is processed:


Scenario 1: The client will owe a deductible. A deductible is the set amount that a client will owe before health insurance starts to pay for services. A client needs to have this amount budgeted for every year. If finances are tight, you are more than welcome to put the client on a payment plan for the claims that process to the deductible. Chances are that they will pay this off within the first part of the year and this will provide your client hope that they can get help


Scenario 2: The client will owe a copay or a coinsurance. A copay is a flat amount that the client must pay for services i.e. $25.00. A coinsurance is a percentage of your allowed amount from the insurance. If the insurance allows $100.00 for a therapy session and the client has a 20% coinsurance, the client will owe $20.00 for each service. This requires that you, the provider, know your fee schedule so you can give your client an accurate cost-estimate before claims are submitted.


Keep in mind that any cost-estimate provided by you or the insurance should be seen as a quote and not a guarantee. This is will help to manage your clients' expectations when they do come to see you and start submitting claims.


Scenario 3: The client has paid off their out-of-pocket maximum and your services will be free. This usually happens in the latter part of the year. It would be fair to state that this is unlikely as we are a few weeks into the year, but it does happen.


Concern #2: Clients might think they have different benefits than what they do


Solutions to #2: The best place to start with this concern is to make sure that you understand how insurance benefits work. If this is something you need help with please give us a call and we would be happy to talk for as long as you need about how insurance works so that you are clear with your clients. Next, you will want to conduct a benefits verification which can be done through a portal or by calling the number on the back of the client's insurance card.


When you call the insurance company you need a few pieces of information:

  1. Are you in-network with the client's plan?

  2. What is the client's deductible for the year?

  3. Does the deductible apply to the mental health benefits for the client?

  4. After the deductible is paid, what is the cost-share?

  5. Are your services covered benefits?

Once you have that information you can provide the client with the best information as possible. Again, keep in mind that this information is simply a quote of coverage and not a guarantee.


Concern #3: Clients may not understand that some providers may be credentialed with a different plan than what they have


Solutions to #3: The solution to this problem rests with knowing exactly who you are credentialed with. This can pose quite a challenge to you especially if you were credentialed with insurance a long time ago. However, the best place to start is by looking at the insurance card. Sometimes, the insurance card will have the company that you need to send claims to, and that company can be different from the company that you are credentialed with. The trend in recent years has been for insurance companies to carve out mental health benefits to other companies. This pattern can create quite a bit of confusion with clients, so it is important that you understand how this process works.


If you are not sure how you are credentialed, give us a call and we can be sure to help you navigate that process.


We know and understand that the beginning of a new year can be particularly difficult to navigate with new insurance plans and different clients. We believe we can be a resource that can take this burden off of your plate completely or help you to understand how to help your clients better. If you have ever wondered if private practice can get easier by outsourcing billing or credentialing, give us a call and we would be happy to see if we can make your private practice a little simpler!

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