Dr. LaFleur is out-of-network with all insurance, meaning that she is not contracted with any insurance companies. If your insurance plan has out-of-network benefits, you may choose to seek reimbursement for a portion of the cost of appointments. She provides families with superbills (receipts) to aid them in this process.

To learn about your benefits and what insurance might cover, call your insurance company and ask:

1. Does my plan have out-of-network mental health benefits?
2. How much does my plan cover for out-of-network mental health services?
3. Which types of sessions are covered and at what rates? More specifically, what is the allowed amount and what is the percentage my plan will cover of that amount?
   • The percentage they specify your plan covers is of an allowed amount, not of Stony Run’s fees. This is why it’s important that you ask about the allowed amounts.
   • Please inquire about each of the following CPT codes (CPT codes are medical service/procedure codes):
     • 90791 (Diagnostic evaluation)
     • 90832, 90834, and 90837 (Individual therapy)
     • 90846 and 90847 (Family therapy
   • They may ask for additional codes or numbers:
     • Stony Run’s Tax ID: 84-4685532
     • Stony Run’s NPI: 1023642675
     • Dr. LaFleur’s NPI: 1982087003
     • Email Dr. LaFleur if you require likely diagnostic codes
4. Is there a number of visits allowed per year? When does my calendar year start?
5. What is my annual deductible? Have I met the annual deductible for this year? Do out-of-network claims apply to my deductible?
6. Is telehealth covered? Is there a difference in reimbursement from in-office services?
7. If Stony Run is out-of-state and my clinician is using their PSYPACT® credential, does that have implications for reimbursement?
8. How do I submit claims and receipts?
9. Is pre-authorization or pre-certification available or required, and if so, how do I pursue it?
10. If you received pre-authorization or pre-certification: What are the dates pre-authorization or pre-certification go into effect and expire? What is the frequency and number of visits authorized? Which CPT or procedure codes will be covered?

Allowable Amounts

If you have out-of-network mental health benefits, it’s important to ask about allowable amounts. The allowable amount for a particular service may be lower than our fees and you will be responsible for paying the difference.

• For example, let’s say our fee for a particular service is $225. And let’s say a particular insurance plan pays 80% of out-of-network mental health benefits. However, the insurance will have an allowable amount for this particular service, and let’s say that it’s $135.
  • In this example, this means that the insurance plan will reimburse 80% of $135.
  • In this example, the person/family would pay $225 on the day of their visit and, after submitting a claim, would be reimbursed by their insurance plan for $108. The cost for this service to the person/family would ultimately be $117.
  • In this example, though the plan covers 80% of out-of-network mental health benefits, due to the allowable amount, it only represents 60% of Stony Run’s fee of $225.
• Here is an equation to help you to calculate your cost after reimbursement:
  • [Stony Run’s fee for the specific service] – ([decimal representing the percentage of out-of-network coverage] x [allowable amount])
  • Using the above example: $225 – (.8 x $135) = $117 
• CPT codes are the codes assigned to each medical procedure or service. A full list of common CPT codes for mental health is available on this page. 

Deductibles

It can also be helpful to learn about whether you have a deductible for out-of-network mental health benefits. For some plans, reimbursement for out-of-network benefits does not begin until you have met your deductible.

The electronic system, Simple Practice, automatically generates and emails “Superbills” (receipts) on the 5th day of each month to the person specified as being responsible for billing. If you have out-of-network benefits, you may decide to submit these superbills to your insurance company for reimbursement. Superbills include information about which service(s) you received and also include diagnostic codes. If you would prefer not to share this information with your insurance, you may choose not to submit claims for reimbursement.

If you would like some help with the claims process, we recommend Reimbursify or The Super Bill.

To complete this process on your own, please follow the instructions provided by your health insurance. The below links may be useful as you get started.

• Aetna
• BlueCross BlueShield
  • CareFirst BCBS
  • BCBS Federal Employee Program
  • To look up a different BCBS plan (then, you’ll navigate to claims information)
• Cigna
• Johns Hopkins EHP
• UnitedHealthcare

Your insurance company is required to have in-network providers with appropriate specialization to serve your needs, or, if such a provider is not available in-network (or there is an inappropriately long wait to work with them), to provide coverage for you to meet with an out-of-network provider. If you are interested in learning more about advocating for out-of-network care options, please click here. 

Some insurance companies do not have adequate in-network providers for:

• OCD
• Anxiety concerns requiring more specialized care
• Evidence-based treatment for children 7 and younger generally, and even more so for those with particular symptoms
• Children with disruptive behaviors including non-compliance, power struggles, or physical aggression

First appointment: Usually 60 minutes and $300. The cost is higher than for other appointments because of the additional time it takes to prepare for the appointment and integrate the information shared. The CPT code is typically 90791. CPT codes are the codes assigned to medical services or procedures.

Follow-up visits: Fees for follow-up visits are based on the length of the visit rather than the specific service. The fee is $225 for 45-minute psychotherapy sessions and $250 for 60-minute psychotherapy sessions.

• Common CPT codes for follow-up visits are 90834, 90837, 90846, and 90847.
• The chosen CPT code is typically based on the length of the appointment as well as who participates and how they participate. The CPT code may vary from one appointment to the next.
• Please note that insurance does not factor in appointment length when reimbursing for family psychotherapy (CPT codes 90846 and 90847) – they will reimburse the same whether the appointment is 45 minutes or 60 minutes.

You have the right to receive a “Good Faith Estimate” explaining how much your care at Stony Run will cost.

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items and services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.

Make sure your health care provider gives you a Good Faith Estimate in writing at least one (1) business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule a service.

If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.

Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 1-800-985-3059. 

Dr. LaFleur is also available to answer your questions and field requests as they pertain to Good Faith Estimates and insurance more generally.