Carefirst out of network benefits suck / allowable charges racket

[Anonymous]

Im so curious where they get the allowable amount when literally no one charges anything in the ballpark.

[Anonymous]

To the people saying "find an in network provider," please know I have spent over a decade looking for an in-network therapist in the DMV and I've only found two in all that time. The first was objectively terrible -- hadn't been in practice for very long, showed up late to every appointment I ever made with him, was unfamiliar with CBT when I mentioned to him it was something that had worked for me in the past, etc.

The other is my current therapist and CareFirst is STILL giving me the runaround on seeing her. She is in-network through the practice she works with and both the practice and I called before I ever saw her to confirm it would be covered and was told yes, it would be covered with my normal co-pay ($30). I get the first bill, it's for $80 (her rate is $145). This is a totally random amount, I've never had an $80 copay, nowhere in any of my plan details is there anything that would explain why this is what they charged me.

I really like this therapist and I'm determined to make it work but they are still not charging my normal copay and there have been multiple weeks where I spent more time on the phone with CF than I did in therapy. In the past I have done short stints of therapy (like 6-8 weeks) with out of network providers who I paid for via an FSA so at least it was paid for with tax-free dollars. But it's ridiculous how much many I spend on a healthcare benefit that is supposedly included in my plan.

I get it, this is what insurers do. But I tell you what, when I take my kid to the pediatrician or see a PT for backpain, I don't have to jump through these hoops -- they charge me the co-pay and we all move on with our lives. It is a problem specifically with mental health services and insurance companies are at the core of the problem because they, for all intents and purposes, run healthcare in the US. We have crap mental healthcare here because that's how insurance companies want it. Think about that next time poor mental health gets blamed for crime, violence, parenting fails, etc. -- we make it as hard and expensive as possible for people to access this care, all so insurance companies can avoid paying a therapist with 20 years of experience who is genuinely great at her job $115 for an hour of her time, at least a third of which will be eaten up by overhead and administration anyway. When's the last time your insurer paid for a $1000 lab test or doctors visit on your plan without a fuss, but apparently a little over $100 for a qualified professional specializing in mental health is too much to bare.

I hate insurance companies. They are making us all sicker.

[Anonymous]

Anonymous wrote:Im so curious where they get the allowable amount when literally no one charges anything in the ballpark.

I have family members in other parts of the country who get charged $80-90 for a 60 minute therapy session, but in lower COL areas.

This is a solvable problem because therapy is something that can actually be done pretty effectively via telemedicine (unlike the vast majority of other medical services) and if we overhauled the system for certifying, providing, and paying for therapy, we could probably create a system with a decent option that got people access to what they need, in-network, while even still leaving a profit margin for insurance companies (why we need to create a profit margin for this idiotic parasitic industry that offers no value add whatsoever is beyond me, but this is consistently what Americans have decided they prefer over single payer for reasons that I will never understand).

But we don't. We just limp along with this hodge hodge system where therapists have to be licensed in the state where you live even if you are receiving tele therapy, and therapists themselves are all expected to be small business-owners even if no aspect of becoming a therapist prepares you for the logistics of that. We have a massive shortage of therapists in this country and we keep waiting for the private sector to solve this and whenever they do, it still just winds up costing too much and not being covered by insurance. There is a fundamental refusal to actually solve this problem.

[Anonymous]

Anonymous wrote:To the people saying "find an in network provider," please know I have spent over a decade looking for an in-network therapist in the DMV and I've only found two in all that time. The first was objectively terrible -- hadn't been in practice for very long, showed up late to every appointment I ever made with him, was unfamiliar with CBT when I mentioned to him it was something that had worked for me in the past, etc.

The other is my current therapist and CareFirst is STILL giving me the runaround on seeing her. She is in-network through the practice she works with and both the practice and I called before I ever saw her to confirm it would be covered and was told yes, it would be covered with my normal co-pay ($30). I get the first bill, it's for $80 (her rate is $145). This is a totally random amount, I've never had an $80 copay, nowhere in any of my plan details is there anything that would explain why this is what they charged me.

I really like this therapist and I'm determined to make it work but they are still not charging my normal copay and there have been multiple weeks where I spent more time on the phone with CF than I did in therapy. In the past I have done short stints of therapy (like 6-8 weeks) with out of network providers who I paid for via an FSA so at least it was paid for with tax-free dollars. But it's ridiculous how much many I spend on a healthcare benefit that is supposedly included in my plan.

I get it, this is what insurers do. But I tell you what, when I take my kid to the pediatrician or see a PT for backpain, I don't have to jump through these hoops -- they charge me the co-pay and we all move on with our lives. It is a problem specifically with mental health services and insurance companies are at the core of the problem because they, for all intents and purposes, run healthcare in the US. We have crap mental healthcare here because that's how insurance companies want it. Think about that next time poor mental health gets blamed for crime, violence, parenting fails, etc. -- we make it as hard and expensive as possible for people to access this care, all so insurance companies can avoid paying a therapist with 20 years of experience who is genuinely great at her job $115 for an hour of her time, at least a third of which will be eaten up by overhead and administration anyway. When's the last time your insurer paid for a $1000 lab test or doctors visit on your plan without a fuss, but apparently a little over $100 for a qualified professional specializing in mental health is too much to bare.

I hate insurance companies. They are making us all sicker.

Amen and hallelujah. But the only way out is single-payer, and the medical lobby (i.e., your doctor, probably) is against single-payer. In other words, doctors are also contributing to us all getting sicker (and they're actually profiting from it).

[Anonymous]

Anonymous wrote:To the people saying "find an in network provider," please know I have spent over a decade looking for an in-network therapist in the DMV and I've only found two in all that time. The first was objectively terrible -- hadn't been in practice for very long, showed up late to every appointment I ever made with him, was unfamiliar with CBT when I mentioned to him it was something that had worked for me in the past, etc.

The other is my current therapist and CareFirst is STILL giving me the runaround on seeing her. She is in-network through the practice she works with and both the practice and I called before I ever saw her to confirm it would be covered and was told yes, it would be covered with my normal co-pay ($30). I get the first bill, it's for $80 (her rate is $145). This is a totally random amount, I've never had an $80 copay, nowhere in any of my plan details is there anything that would explain why this is what they charged me.

I really like this therapist and I'm determined to make it work but they are still not charging my normal copay and there have been multiple weeks where I spent more time on the phone with CF than I did in therapy. In the past I have done short stints of therapy (like 6-8 weeks) with out of network providers who I paid for via an FSA so at least it was paid for with tax-free dollars. But it's ridiculous how much many I spend on a healthcare benefit that is supposedly included in my plan.

I get it, this is what insurers do. But I tell you what, when I take my kid to the pediatrician or see a PT for backpain, I don't have to jump through these hoops -- they charge me the co-pay and we all move on with our lives. It is a problem specifically with mental health services and insurance companies are at the core of the problem because they, for all intents and purposes, run healthcare in the US. We have crap mental healthcare here because that's how insurance companies want it. Think about that next time poor mental health gets blamed for crime, violence, parenting fails, etc. -- we make it as hard and expensive as possible for people to access this care, all so insurance companies can avoid paying a therapist with 20 years of experience who is genuinely great at her job $115 for an hour of her time, at least a third of which will be eaten up by overhead and administration anyway. When's the last time your insurer paid for a $1000 lab test or doctors visit on your plan without a fuss, but apparently a little over $100 for a qualified professional specializing in mental health is too much to bare.

I hate insurance companies. They are making us all sicker.

Look, I hate insurance companies with a passion. But that $1000 lab fee isn't going to happen every week for a year.

[Anonymous]

I’m using Headway for my son’s weekly therapy. It’s telehealth and 100% covered by Carefirst with no copay. Just sharing as an option.

[Anonymous]

Anonymous wrote:1) This is how a PPO works. If you don't want to be paying out of pocket like this, you need to find an in-network provider. If you have trouble doing that, call the insurance company and ask for help doing so.

2) Most of us can't afford weekly therapy. If you are able to swing it at all with copays and deductibles etc, consider yourself very fortunate.

3) Of course you have to submit paperwork. That is also one of the benefits of using in-network providers; they handle billing.

Thanks for your thoughts... but you miss my point. The money / paperwork isn't really the issue as much as their intent to screw over people as part of their published business model. Offering out of network services, but not really offering them, is what I'm talking about. My premium is higher because of out of network benefits, but they aren't really benefits. It's a scam and there's a smokescreen around what's really going on when you evaluate and sign up for insurance. They should be required to publish a list of their "allowed amounts" for all codes for that insurance plan. This extra disclosure would be helpful to both alerting people to the issue and also letting them decide if it's worth it.

[Anonymous]

Anonymous wrote:I’m using Headway for my son’s weekly therapy. It’s telehealth and 100% covered by Carefirst with no copay. Just sharing as an option.

Thanks - will look into this.

[Anonymous]

Anonymous wrote:It varies by the plan your employer has selected. I have Carefirst and my allowed amount for a $200 therapy appt is $150. For many years, we had a different Carefirst plan that had super low allowed amounts, so I feel your pain.

what's your plan called? is it on the DC Health Xchange?

[Anonymous]

Anonymous wrote:

Anonymous wrote:It varies by the plan your employer has selected. I have Carefirst and my allowed amount for a $200 therapy appt is $150. For many years, we had a different Carefirst plan that had super low allowed amounts, so I feel your pain.

what's your plan called? is it on the DC Health Xchange?

No - It’s an employer sponsored plan.

[Anonymous]

Anonymous wrote:

Anonymous wrote:To the people saying "find an in network provider," please know I have spent over a decade looking for an in-network therapist in the DMV and I've only found two in all that time. The first was objectively terrible -- hadn't been in practice for very long, showed up late to every appointment I ever made with him, was unfamiliar with CBT when I mentioned to him it was something that had worked for me in the past, etc.

The other is my current therapist and CareFirst is STILL giving me the runaround on seeing her. She is in-network through the practice she works with and both the practice and I called before I ever saw her to confirm it would be covered and was told yes, it would be covered with my normal co-pay ($30). I get the first bill, it's for $80 (her rate is $145). This is a totally random amount, I've never had an $80 copay, nowhere in any of my plan details is there anything that would explain why this is what they charged me.

I really like this therapist and I'm determined to make it work but they are still not charging my normal copay and there have been multiple weeks where I spent more time on the phone with CF than I did in therapy. In the past I have done short stints of therapy (like 6-8 weeks) with out of network providers who I paid for via an FSA so at least it was paid for with tax-free dollars. But it's ridiculous how much many I spend on a healthcare benefit that is supposedly included in my plan.

I get it, this is what insurers do. But I tell you what, when I take my kid to the pediatrician or see a PT for backpain, I don't have to jump through these hoops -- they charge me the co-pay and we all move on with our lives. It is a problem specifically with mental health services and insurance companies are at the core of the problem because they, for all intents and purposes, run healthcare in the US. We have crap mental healthcare here because that's how insurance companies want it. Think about that next time poor mental health gets blamed for crime, violence, parenting fails, etc. -- we make it as hard and expensive as possible for people to access this care, all so insurance companies can avoid paying a therapist with 20 years of experience who is genuinely great at her job $115 for an hour of her time, at least a third of which will be eaten up by overhead and administration anyway. When's the last time your insurer paid for a $1000 lab test or doctors visit on your plan without a fuss, but apparently a little over $100 for a qualified professional specializing in mental health is too much to bare.

I hate insurance companies. They are making us all sicker.

Look, I hate insurance companies with a passion. But that $1000 lab fee isn't going to happen every week for a year.

NP here. Fair enough. But for most people, with adequate treatment, therapy, will not last forever and can support better long term health outcomes.

OP, we had a similar experience with our of network providers. I got very, very lucky to finally find a good practice that started accepting CareFirst. Recommended the practice to a friend shortly after my child started and they had already stopped accepting new patients. It’s incredibly frustrating.

[Anonymous]

NP. Also with a CareFirst PPO plan from DC Healthlink. They have the absolute lowest “allowable” amounts and providers hate working with them. It is completely unpredictable. I tried their HMO 2 years ago and it was worse. At least now we have an HSA.

We use only in-network providers and it is still cost prohibitive to get all the necessary care I need. But I can’t afford a higher plan; mine is already subsidized. We get barebones preventative care covered; everything else is OOP until the high deductible is met. This is what they call “affordable”.

[Anonymous]

Anonymous wrote:

Anonymous wrote:To the people saying "find an in network provider," please know I have spent over a decade looking for an in-network therapist in the DMV and I've only found two in all that time. The first was objectively terrible -- hadn't been in practice for very long, showed up late to every appointment I ever made with him, was unfamiliar with CBT when I mentioned to him it was something that had worked for me in the past, etc.

The other is my current therapist and CareFirst is STILL giving me the runaround on seeing her. She is in-network through the practice she works with and both the practice and I called before I ever saw her to confirm it would be covered and was told yes, it would be covered with my normal co-pay ($30). I get the first bill, it's for $80 (her rate is $145). This is a totally random amount, I've never had an $80 copay, nowhere in any of my plan details is there anything that would explain why this is what they charged me.

I really like this therapist and I'm determined to make it work but they are still not charging my normal copay and there have been multiple weeks where I spent more time on the phone with CF than I did in therapy. In the past I have done short stints of therapy (like 6-8 weeks) with out of network providers who I paid for via an FSA so at least it was paid for with tax-free dollars. But it's ridiculous how much many I spend on a healthcare benefit that is supposedly included in my plan.

I get it, this is what insurers do. But I tell you what, when I take my kid to the pediatrician or see a PT for backpain, I don't have to jump through these hoops -- they charge me the co-pay and we all move on with our lives. It is a problem specifically with mental health services and insurance companies are at the core of the problem because they, for all intents and purposes, run healthcare in the US. We have crap mental healthcare here because that's how insurance companies want it. Think about that next time poor mental health gets blamed for crime, violence, parenting fails, etc. -- we make it as hard and expensive as possible for people to access this care, all so insurance companies can avoid paying a therapist with 20 years of experience who is genuinely great at her job $115 for an hour of her time, at least a third of which will be eaten up by overhead and administration anyway. When's the last time your insurer paid for a $1000 lab test or doctors visit on your plan without a fuss, but apparently a little over $100 for a qualified professional specializing in mental health is too much to bare.

I hate insurance companies. They are making us all sicker.

Look, I hate insurance companies with a passion. But that $1000 lab fee isn't going to happen every week for a year.

Maybe, maybe not. Some people do have conditions that require frequent testing. I had to have tons of bloodwork done when I was pregnant, I'm sure thousands of dollars in lab work over the course of 9 months, but it was all completely covered with no copay at all. My DH has chronic back issues and we've never had problems getting his physical therapy or visits to the orthopedist covered. And they'll be very up front that they cover x number of PT visits with x copay, and after that you are out of pocket. I think the only issue we've ever run into is way back when he was diagnosed, they wouldn't cover an MRI because the issue was considered "acute" at the time so he only had an x-ray. But then a year later when he'd done a round of PT and meds and the problem had recurred, he got the MRI and it was fully covered.

But with mental health stuff, anything other than a prescription for anti-depressants is treated like an impossibility, even though the providers are often WAY less expensive than physical medicine specialists and even if you are trying to follow the rules of the insurance laid out in the section of your policy on mental health services.

Insurers could also actually look into mental health services to come up with ways to treat and meet these needs without racking up massive fees. In countries with single-payer, there are a lot of mental health services and programs that are meant to address lower level mental health needs so that it's cost effective for the system. For instance CBT is an evidenced-based therapy that has shown to be very effective for depression, so in the UK there is an online CBT program you can enroll in where you essentially join a "class" of people to learn CBT methods from a licensed therapist, and there is a group therapy component. But because it's done online and program is standardized, it can be offered much more cheaply than 1:1 therapy.

Imagine if your insurance offered you something like that. I would personally jump at it. People with mental health problems want solutions, most people are not actually eager to sign on for years of talk therapy with no visible benefit. But insurers do not care about mental healthcare and as a country we have essentially abandoned people to whatever private services they can cobble together, and then we're surprised when we see negative social impacts from untreated mental health issues. It's non-sensical.

[Anonymous]

This isn’t a CareFirst thing. It’s how things worked when I had UHC and had to go OON for specialists. My first year, I was $20k OOP.

CareFirst has a better network in this area.

[Anonymous]

My CareFirst plan has a partnership with AbleTo for tele-therapy. Might be worth a look. It’s covered at the PCP level (for me, it’s $10).