One of the most common questions we are asked when someone inquires about our services is “Will our insurance cover music therapy?”
Well… that's a loaded question. Off the cuff, my answer would be, “yes”, however, there are so many factors to weigh before that question can be answered correctly.
Music Therapy is still a very new therapy concept for many of these insurance carriers. So new, that there is not even a procedure code (CPT) specific to music therapy. I spend a great deal of my day educating insurance companies about who we are, what we do, and why this is a “medically necessary” therapy.
Although highly frustrating at times, I do know that with each call, each appeal…I am educating just one more person, one more medical reviewer, one more insurance provider, one more customer service representative about the benefits of music therapy. One day, hopefully soon, we will no longer be considered an “alternative or experimental therapy” and music therapy will specifically be listed as a covered benefit on most plans.
So, how do we know if your plan will cover MT?
The first question I would ask is “who is your insurance provider”? We have tremendous success with Aetna, Coventry, Humana, BCBS plans administered outside of GA and United Healthcare; just to name a few. Unfortunately, BCBS of GA, Medicaid and Tri-Care will not consider music therapists as covered providers. As of January 1, 2014 it is required that all MT’s practicing in Georgia be licensed by a state. It is our hope that state licensure will open the door to coverage from these three entities in the near future.
The next question I would ask…. “Is your plan an HMO (Health Maintenance Organization”? All MT, no matter where it is obtained, is considered an out of network benefit and therefore, not covered by HMO’s.
Once we establish the answers to those first few questions, I proceed by verifying your benefits and coverage. Each plan is different and benefit levels vary. I will contact your insurance company and inquire about your specific plan. Since there is no CPT code specific to MT, I verify the therapy and/or mental health benefits associated with your account, as the CPT codes appropriately used by MT’s fall under these categories.
I inquire as to how many visits per year your plan allows for each of these modalities, how many have been used, and where you stand on your out of network deductible and out of pocket max for the year. Obviously, many of our families are involved in other therapies, so the number of visits left is a huge factor regarding coverage. Furthermore, if your out of network deductible is very high, billing your insurance may be more expensive in the long run. I will analyze this information for you and let you know if using your insurance plan is a financially feasible option. Our goal is to maximize your benefits and find the least expensive way to cover our services.
Finally, I will inquire as to whether there are any exceptions to your plan. Although your plan may cover the above mentioned therapies…there may be exceptions regarding coverage of a specific diagnosis, treatment modality, age of the client, etc. and this can cause your claim to be denied.
Of course, the answer to whether or not insurance will cover MT is ultimately up to your insurance company. I am always very careful to remind our families that a verification of benefits is not a guarantee of coverage and that our relationship is with you and not your insurance company.
Each claim is individually reviewed for approval. Some plans require medical reviews after a defined number of visits or prior to approval. When that happens, their decision to cover services may completely change if they feel that the client is not progressing, the treatment is not appropriate, or just because they don’t want to cover it any longer. Often times, we are asked to provide treatment notes, the treatment plan, an explanation of our therapeutic activities and a letter of medical necessity and prescription from your physician in order to prove medical necessity. If they decide to deny coverage, I typically fight to alter that decision in the form of an appeal. With collaboration from our therapists, I can happily say that we do win appeals. Not all the time, but quite often!
So, as you can see, the question “Will our insurance cover music therapy?” is a loaded question. I can never promise that it will, but what I can promise is that we, at The George Center for Music Therapy, will do everything in our means to exhaust all options. We take pride in the fact that we bill insurance successfully for approximately 80% of our patients. While it isn’t always seamless and easy, it can be successful. And with each success, it just opens the door wider for our future patients.
Insurance is not the only means of 3rd party funding for music therapy. There are many grants, scholarships and waivers that also cover our services. We know of several and would be happy to share them with you. Networking with other families going through similar circumstances to yours is another effective means of learning of other options.
If you would like for me to check on your insurance benefits or inquire about additional funding options, please feel free to contact me at 770-998-9599 ext. 3 and ask for Christy!