Fee Schedule
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Dr. Benzl accepts Anthem Blue Cross. If you have Anthem, please call your member services to verify coverage. At this time, Dr. Benzl is not an in-network provider with any other insurance company. Dr. Benzl is considered an out-of-network provider for most PPO plans. Therefore, payment to Dr. Benzl is due at time of service, and clients may seek reimbursement from their insurance company. Most PPO insurance plans will reimburse a portion of the cost to see Dr. Benzl, after an out-of-network deductible is met. Every insurance plan is different, therefore, it is important to speak with your insurance company about their reimbursement rates and coverage for mental health services. Dr. Benzl will provide a superbill with the necessary information for your insurance company after each service, or on a monthly basis for those clients who engage in weekly psychotherapy. It is the client's responsibility to submit these superbills to their insurance company for reimbursement.
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Out of Pocket Appointment Fees
Intake 60 minute appointment: $450
Medication Management: 30 minute appointment $225
Medication Management+ Psychotherapy: 45-50 mins appointment $300
Administrative Fees
Prior authorizations: $30 minimum, up to $50 for extensive prior authorizations
Controlled substance requests between appointments: $20
EDD paperwork: $40
FMLA paperwork: $20
Medical Letters: $20
Other Forms: $50 per 10 mins of time
Phone appointments: $70 per 10 mins of time
No show/late cancellation fee- $175, 48 business hour notice of cancellation required to avoid fee, however, if there are appointments available within the same week, this fee will be waived. Also, if there is a medical or family emergency, this fee will be waived. I cannot waive work emergencies or forgotten appointments.
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SURPRISE BILLING PROTECTION FORM
The purpose of this document is to let you know about your protections from unexpected medical bills. It also asks whether you would like to give up those protections and pay more for out-of-network care.
You’re getting this notice because this provider and/or facility isn’t in your health plan’s network. This means the provider or facility doesn’t have an agreement with your insurance plan.
Getting care from this provider or facility could cost you more.
If your plan covers the item or service you’re getting, federal law protects you from higher bills:
· When you get emergency care from out-of-network providers and facilities, or
· When an out-of-network provider treats you at an in-network hospital or ambulatory surgical center without your knowledge or consent.
Ask your health care provider or patient advocate if you need help knowing if these protections apply to you.
If you sign this form, you may pay more because:
· You are giving up your protections under the law.
· You may owe the full costs billed for items and services received.
· Your health plan might not count any of the amount you pay towards your deductible and out- of-pocket limit.
· Your health plan may cover partial of the amount.
Contact your health plan for more information.
You shouldn’t sign this form if you didn’t have a choice of providers when receiving care. For example, if a doctor/provider was assigned to you with no opportunity to make a change.
Before deciding whether to sign this form, you can contact your health plan to find an in-network provider or facility. If there isn’t one, your health plan might work out an agreement with this provider or facility, or another one.
Please refer to your “Good Faith Estimate for Health Care Items and Services” sent via the secure portal for an estimate of what you can expect to pay. This document includes your specific health care information and estimate. Out-of-network provider(s) or facility name: Karla Benzl, MD
Total cost estimate of what you may be asked to pay: It is your ethical right to determine your goals for treatment and how long you would like to remain in therapy unless you are pursuing mandatory treatment. Please see the breakdown of possible fees in the “Good Faith Estimate for Health Care Items and Services.”
Out of Pocket Appointment Fees
Intake 75 minute appointment: $450
Medication Management: 30 minute appointment $225
Medication Management+ Psychotherapy: 45-50 mins appointment $300
Administrative Fees
Prior authorizations: $30 minimum, up to $50 for extensive prior authorizations
Controlled substance requests between appointments: $20
EDD paperwork: $40
FMLA paperwork: $20
Medical Letters: $20
Other Forms: $50 per 10 mins of time
Phone appointments: $70 per 10 mins of time
No show/late cancellation fee- $100 fee and 48 business hour notice of cancellation required to avoid fee, however, if there are appointments available within the same week, this fee will be waived. Also, if there is a medical or family emergency, this fee will be waived. I cannot waive work emergencies or forgotten appointments.
â–º Review your detailed estimate.
â–º Call your health plan. Your plan may have better information about how much of these services are reimbursable.
â–º Questions about your rights? For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call (800) 368-1019.
Prior authorization or other care management limitations
Except in an emergency, your health plan may require prior authorization (or other limitations) for certain items and services. This means you may need your plan’s approval that it will cover an item or service before you get them. If prior authorization is required, ask your health plan about what information is necessary to get coverage.
More information about your rights and protections
Visit <https://www.cms.gov/files/document/model-disclosure-notice-patient-protections-against-surprise-billing-providers-facilities-health.pdf> for more information about your rights under federal law.
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