Some Frequently Asked Questions:

 

(1) Is the Kartini Clinic contracted with my insurance company?

 

Kartini Clinic has and will continue to make every effort to contract with those insurance carriers who provide quality mental health policies and who support the medically-based treatment model used at the Clinic.

By the time you read this you may have made an appointment already and know if your insurer is contracted with the Kartini Clinic. If you aren’t sure whether your insurer is contracted, call the Clinic and ask for the business office.

(2) If my insurance is contracted, what are the medical and mental health benefits under my plan?

 

We will contact your insurance company and request a summary of your benefits. We will provide you with a written summary of the information provided to us. We strongly urge you to verify any information provided to you, as insurance companies have been known to provide inaccurate information to providers. As you ultimately will be responsible for any outstanding balances, it is important you satisfy yourself that all benefit information is accurate and up-to-date.

 

Authorization for Treatment

Kartini Clinic clinical staff will obtain any treatment authorization(s) required under your insurance policy, provided your insurance company has given us accurate information regarding any authorization requirements.

 

Payment

As a patient of a contracted provider you will be responsible only for your copays at the time of you appointment. Your insurance company will reimburse Kartini Clinic directly, in accordance with the benefits included in your insurance policy. Any subsequent balance (deductibles, co-insurance, etc.) will be your responsibility to pay. Kartini Clinic will bill your for these balances.

 

Claims

Kartini Clinic will file all of your claims directly to your insurance company. You should receive a copy from your insurance company, of any payments made to us, in the form of an Explanation of Benefits (EOB).

 

 

(3) If my insurance company is not contracted with Kartini Clinic, what are my out-of-network medical and mental health benefits?

 

Unfortunately it is not possible to contract with every insurance carrier. If your carrier is not contracted with the Clinic, you, as the member, are responsible for complying with your insurance carrier’s policies. This begins with an authorization for treatment (see below).

If your insurance carrier is not contracted with the Clinic, you may still be able to gain partial reimbursement for any treatment costs. Many policies provide out-of-network benefits. Ask your insurance carrier if you have such benefits.

Even if you are informed that no such benefit exist under your policy, you may still request to have treatment at the Clinic covered. Many insurance plans provide for reimbursement if you can prove that no similar treatment program exists in your area. Your primary care physician can help you make this case to your insurance carrier. Please be advised that the Clinic can furnish you and/or your doctor with information about our program, but we cannot intervene to write letters, call medical directors, etc. on your behalf. It is up to you and your doctor to secure approval for treatment at the Clinic.

 

Authorization for Treatment

If your insurance is not contracted with Kartini Clinic you will be responsible for getting pre-authorizations for treatment for your appointments. This means you will need to call your insurer and let them know you have scheduled, or plan to schedule, appointments with us. Your insurance carrier will tell you what to do next. If you fail to obtain a pre-authorization for treatment, your claims may be denied.

Be advised that, unlike medical visits, most policies place a limit on the number of mental health visits. It is important for you to know how many visits you are entitled to under your policy. If you do not know, call your insurance carrier. If you need help determining how many visits you have had at the Clinic to date, please ask our front office.

 

Payment

If your insurer is not contracted, you will be asked to pay at the time of your visit. Reimbursements from your insurer must go directly to you rather that to the Clinic. Kartini Clinic cannot accept reimbursement from insurance companies for services already paid by you. Such payments are often made to Kartini in error and have to be returned to the insurance company.

Please note that refusal to pay at the time of your visit may result in the cancellation of your appointment.

 

Claims

If you so chose, we will file all necessary claims directly to your insurance company, even if we are not contracted with your insurer. We provide this service because we understand how difficult it can be to manage complex paperwork while simultaneously struggling to care for a sick child. However, we cannot guarantee payment or the correct processing of your claims by your insurance carrier. We do our utmost to follow industry standard guidelines for claims, but each insurer is different and some claims can be delayed for extensive periods of time.

In the case of claim denials, the balance of any visit will fall to the patient’s or guarantor’s responsibility. As an out-of-network provider, the Kartini Clinic is entitled to payment even if your insurance carrier refuses to cover the services provided to you. It is therefore essential that you monitor the progress of reimbursement by your insurance carrier. If a claim is more than 30 days old, call your insurance carrier and ask about the status of your claim.

(4) What is the difference between medical and mental health benefits, and how can this affect my treatment at Kartini Clinic?

 

All insurance policies are divided into two parts: medical and mental health benefits. Each policy has a different set of benefits for medical and mental health, with mental health benefits often being limited to a certain number of visits per calendar year or 24-month period.

There are three different types of benefits that are usually accessed for treatment at Kartini. They are:

1. Outpatient Medical

2. Outpatient Mental Health

3. Residential/ Intensive Outpatient/ Partial Hospitalization (DTU or IOP)

 

 

Outpatient Medical benefits:

1. Inpatient rounds with a doctor (Even with a child in hospital, Kartini services are considered outpatient services, since we are NOT a hospital but simply providing service to a patient who is in the hospital.)
2. Outpatient medical exams with MD (often referred to by insurance carriers as “office visits”)
3. Physical therapy treatments

 

Outpatient Mental Health:

These benefits are usually limited to a set number of visits by the insurance company and used for three services:

1. Family Therapy
2. Group Therapy
3.Individual Therapy

4. Initial Psychiatric Evaluations

 

Intensive Outpatient / Partial Hospitalization/ Residential:

These benefits are usually strictly limited and used for:

1. Day Treatment Unit (patients under the age of 18)
2. Intensive Outpatient Program (patients 18 and over)

 

(5) What is mental health "parity" and how does it affect me?

 

The Oregon legislature passed a law requiring that health insurance plans provide mental health benefits that are on par with medical benefits under the same plan. This statute is referred to as the mental health "parity" law. Under this law you may be eligible for extended mental health benefits. You should contact your insurance company for answers about your specific benefit plan.

 

 

(6) What do I do when I'm not getting what I need from my insurance company?

 

The name of the game is persistence. Insurance companies are far more responsive if they know you are going to advocate for your rights and those of your child. You are the paying member, and at the end of the day you are the only person who can ensure that you get what you are entitled to. Most importantly, you are ultimately responsible for payment.

If you have any questions, call your insurance carrier right away, and don’t get off the phone until you are satisfied your question has been answered. Here are a few tips when talking to insurance companies:

Tip #1: when talking to your insurer, be sure always to get a name and, if possible, a direct line or extension number of the person you are speaking with. Take notes, and don’t be afraid to ask for a supervisor if you are not getting the answers you need. You have paid for this insurance and persistence is usually rewarded.

Tip #2: we recommend that every Kartini Clinic parent and/or patient seek a care manager. A care manager is a single point of contact between you and your insurer. Such a person will know your name and the particular requirements of your case. A care manager will be able to help with authorizations for treatment as well as with claims that are either denied or paid incorrectly.

If asked why you want a care manager, you may inform them that we recommended you seek one because of the complicated nature of eating disorder treatment, particularly the transition from inpatient to day treatment and eventually outpatient. Each step in the process usually accesses separate benefits within your plan. Most insurers do not have enough trained staff to ensure your claims are looked at by someone who understands this. And be prepared for them to say no, but keep asking. In the end, again, your persistence is likely to pay off.

Tip #3: when insurance companies say they have "paid" a claim, this does not correspond to the customary meaning of the phrase. What they often mean is the claim has been "released" for payment and will take another two weeks (or more) to arrive at its intended destination. To determine whether a check has actually been cut, ask for a check or voucher number. If they can't give you one, it means they haven't paid the claim yet. It is also useful to ask where the check was sent. Unfortunately insurance companies often send payments to providers' offices when they should be sent to you (and occasionally vice versa), and that can result in further delays as such checks have to be returned to the insurance company in order to be reissued. Kartini Clinic will not sign over insurance checks to anyone.