Most patient billing complaints start here, weeks before the bill. A careful verification means the patient hears the right number before their first session, not after their fifth.
What to collect
- Patient full name, date of birth and address exactly as on the card
- Member ID, group number and the payer phone number on the back of the card
- Subscriber name and date of birth if the patient is a dependent
- Any secondary insurance
What to verify
| Question | Why it matters |
|---|---|
| Is the plan active today? | Inactive coverage means the whole session is self-pay. |
| Who manages behavioral health? | Carve-outs (for example Optum or Carelon) process the claims, not the medical payer. |
| Is the provider in network? | Out-of-network benefits are often much worse or zero. |
| Deductible: amount and how much is met | Until met, the patient may owe the full allowed amount. |
| Copay or coinsurance for outpatient mental health | This is the per-session amount after the deductible. |
| Does the deductible apply to this service? | Many plans waive it for office visits; some don’t. |
| Authorization required? Visit limits? | Missing auths cause denials that are hard to recover. |
| Telehealth covered the same as in person? | Some plans pay telehealth differently. |
Always write down the reference number of the call or portal check, the date and the name of the representative.
Prior authorizations
Some plans require approval before treatment starts, or after a set number of sessions. Psychological testing, intensive outpatient programs and some Medicaid plans almost always do.
- Ask during verification: “Is prior authorization required for outpatient psychotherapy, CPT 90837?”
- If yes, submit the request with what the payer asks for (diagnosis, treatment plan, frequency). The clinician supplies clinical details.
- Record the auth number, number of approved visits, and start and end dates in the patient’s account.
- Set a reminder when 2–3 visits remain or two weeks before the end date, so a renewal is filed before it lapses.
Sessions without a valid authorization usually deny (CO-197 / CO-15) and are hard to recover.
Turning benefits into an estimate
Example: deductible $1,000, $250 met, then 20% coinsurance. Allowed amount for 90837 is $150.
- Sessions 1–5: patient pays $150 each until the remaining $750 is met.
- After that: patient pays 20% ($30) per session.
Explain it to the patient in plain words: “For the first five sessions you’ll pay about $150 each while your deductible is being met. After that, it’s about $30 per session.” Then send it in writing.
Good habits
- Re-verify at least monthly and every January.
- If a patient mentions a new job, marriage or turning 26, re-verify that day.
- Never guess. “Let me confirm with your plan and call you back by tomorrow” is a better answer than a wrong number.