Insurance & Billing
We accept PPO plans for Aetna, Baylor Scott & White, BCBS, Cigna, Magellan, and Tricare South insurance plans. We do not bill secondary insurance plans and do not accept Medicaid or Medicare insurance. You will be responsible for ALL co-pays, deductibles and non-covered services. We accept all major credit cards and cash.
Our billing office will submit a claim to your insurance carrier. When the claim is processed, your insurance will send an Explanation of Benefits (EOB) to you. Please note that the name of the provider on the EOB will be Lake Worth Counseling. For covered services, you will be responsible for anything that is patient responsibility, including deductible, co-insurance, etc. If you have questions about your benefits, please contact your insurance provider.
For any questions related to claims and billing, please contact Patient Coordinator, Theresa Ferrell, Phone(817) 238-0106. Fax (817)238-8333. Email: TheresaF@LWC.CARE
Working With Your Insurance
Health insurance can seem quite confusing – and different plans have different rules and regulations depending on which state you live. It is ultimately up to you, the patient, to understand the details of your plan’s terms, benefits and coverage options in order to avoid any unexpected costs and hassles.
Do Insurance Companies Require a Diagnosis to Pay for my Session?
Insurance companies require that you receive a mental health diagnosis in order to pay your claim. In our experience insurance companies will accept a ‘soft diagnosis’. Something like “Adjustment Disorder” which is temporary and non-threatening. But some insurance companies refuse to reimburse for “softer diagnoses”, and require more severe diagnoses to pay for your session. Even common experiences like “Depression” go into your permanent record and may affect certain policies such as life insurance coverage. Couples relationship issues, parent/child troubles, normal grieving, or “just having a hard time” are all things that are usually NOT covered unless a diagnosis is given. Before you use insurance you may want to consider that the diagnosis a permanent part of your medical record. If you choose to not use your behavior health benefits for this reason please let us know you will be a self-pay client and that you elect not to have a diagnosis filed for privacy reasons.
What About Private Pay?
When you privately pay for your mental health care, no diagnosis is required and your confidentiality is assured. Cost for care range from $125 to $135 per session. We also have licensure candidates who can accept patients at a reduced fee of $60 to $100. Weekly sessions are often preferred, but meeting less frequently can be economical and ultimately as beneficial. When you call Lake Worth Counseling for an appointment, we will help you find the therapist at an appropriate rate for your situation.
Health Insurance Providers
Please check with your medical insurance provider directly to confirm your coverage and benefits.
We are listed as participating providers for the following:
- BCBS of Texas PPO
- Aetna PPO
- Cigna/Great West Healthcare PPO
- Baylor Scott & White
- Tricare (South Region); Tricare Prime (all Tricare patients must have a prior authorization on file)
Out-of-Network plan: include but not limited to the following insurance plans – Medicare, Medicaid, Humana, Life Sync, Wellmart, Healthscope, and Health Source which are considered out-of-network plans with Lake Worth Counseling. We are happy to discuss other options for your care.
Out-Of-Network means we are NOT contracted with your insurance company and do not accept your insurance plan. If you are “Out-Of-Network” we are happy to provide you with a “Superbill” receipt to give to your insurance company for reimbursement. You are required to pay the session fee up front in full. Due to patients having a higher deductible this allows you to still access quality services with the counselor of your choice and receive a partial refund for the services if applicable. Please contact your insurance company for details as each plan as the amount of reimbursement may vary by plan.
A Note on Psychological Testing
We will seek prior authorization for testing ordered by Dr. Jon Shepard, Licensed Psychologist. Due to changes in insurance carrier policies, many patients have plans with a high deductible. Please note prior authorization does not guarantee payment from your insurance provider. You may still be responsible for additional payment depending on your insurance benefits. Please contact your insurance company to determine your deductible and any potential charges you may incur.
Below is a list of basic terms you may come across while learning more about health insurance:
A cost-sharing arrangement between an insured person and health insurance company wherein the insured person pays a fixed dollar amount for covered medical services. For example, a PPO may require a $20 “co-payment” for normal services delivered during a physician office visit; after which the insurance company often pays the remainder.
A cost-sharing arrangement between an insured person and health insurance company wherein the insured person pays a stated percentage of expenses for covered medical services after the deductible amount, if any, was paid.
A cost-sharing arrangement between an insured person and health insurance company wherein the insured person is required to pay a fixed dollar amount each benefit period (typically a year) before the health insurance company will reimburse for covered health care expenses. Plans may have both per individual and family deductibles.
Explanation of Benefits (EOB)
Statement sent by insurance companies to persons who have experienced a claim under the health plan. An EOB details the charges for the services received, the amount the health insurance company will pay for those services, and the amount the insured person will be responsible for paying
First Dollar Coverage
A term for not having to meet a yearly deductible amount prior to receiving reimbursement or payment for a medical service.
Health Maintenance Organization (HMO)
A prepaid health plan which covers certain aspects to patient treatment; for instance: doctors’ visits, emergency care, surgery, lab tests and therapy. In a HMO, one must choose a primary care physician who then coordinates all care and makes referrals to any specialists that may be required. Also in a HMO, one must use the doctors, hospitals and clinics participating in a specified network (usually within a specified geographic area).
A cap on the benefits paid for the duration of a health insurance policy. Many policies have a lifetime limit of $5 million, which means that the insurer agrees to cover up to $5 million in covered services over the life of the policy. Once the $5 million maximum is reached, no additional benefits are payable.
Managed Care Plan
Health insurance plan which generally provides comprehensive services to their members (“enrollees”), offering financial incentives for patients to use their participating providers in a specified network. HMO and PPO plans are both examples of a managed care plan.
Physicians, hospitals or other providers of medical services that have agreed to participate in a managed care network – offering their services at discounted rates and meeting other negotiated contractual provisions. They are also sometimes called “participating providers”.
The total dollar amount an insured person is required to pay for covered medical services during a specified period, such as one year. This may also be called the “stop-loss limit” or “catastrophic expense limit”.
Preferred Provider Organization (PPO) plan
A health insurance plan where coverage is provided through a network of selected health care providers (such as hospitals and physicians) who have negotiated contracts with the insurance company to offer their services at discounted costs. Enrollees may go outside the network for care, but this would most likely incur larger costs to the enrollee (e.g.: a higher deductible or higher, non-discounted, charges from the providers).
Primary Care Physician (PCP)
The primary contact for enrollees within a health plan, this is often a family physician, internist, or pediatrician. In a managed care plan (e.g.: a HMO or PPO), a PCP monitors patient health, treats and/or coordinates most patient health problems, and if required by the plan, refers patients to specialists when necessary.
A review of the need for health care services or products, before services are rendered or products are provided. This term refers to a decision made by the health insurance plan provider to cover or not cover the charges before any services/products are provided.
A contracted limit in a health insurance policy that provides for 100% payment of expenses after the total patient’s/group’s out-of-pocket expenses exceed a certain dollar amount.
Usual and Customary (U&C) Charge
The basis for how conventional indemnity plans operate. U&C charges is a term used for commonly charged or prevailing fees for health services within a geographic area. A fee is generally considered to be reasonable if it falls within the parameters of the average or commonly charged fee for the particular service within that specific community. This is sometimes also referred to as “Reasonable and Customary (R&C) Charge”. In contrast, PPO plans often operate on a negotiated (fixed) schedule of fees.