Billing and Insurance

Falcone Institute is a private-pay practice. We work with our clients to establish a fee structure based on hourly rates or within an integrated program format. We collect fees on per-session, weekly or monthly basis.

Falcone Institute is an out-of-network private practice with all insurances. We do provide superbills with billable CPT codes and corresponding diagnosis codes for reimbursement consideration, but consideration and approval are contingent on your individual insurance policy. In some cases, insurances will reimburse our services at the in-network co-insurance rate if there are no similar providers in and around your area of residence. Insurance coverage differs by policy and company, so if you'd like to learn more, we encourage you to ask your insurance company for additional details.*

Although we are considered an out-of-network facility, we do have established relationships with the following companies:

Blue Shield of CA: Falcone Institute is an out-of-network provider "on record."
Tricare West: Falcone Institute is an approved non-network provider**
SEALKIDS, Inc.: Falcone Institute is an authorized SEALKIDS service provider

When contacting your insurance to learn more about your specific policy, there is some key information to know. Below are a few questions that you can ask your insurance company to get clarity on your specific policy and coverage:

Psychotherapeutic Services

Does my policy include an outpatient mental health or behavioral health benefit?

If yes: Does my policy include coverage for a Licensed Marriage and Family Therapist (LMFT)?
If yes: Does my policy include out-of-network coverage for an LMFT?
If yes: what is the reimbursement rate for out-of-network LMFTs?
What is the out-of-network reimbursement rate for the initial assessment (CPT 90791)?
What is the out-of-network reimbursement rate for individual psychotherapy sessions (CPT 90832, 90834, and 90837)?
Is family therapy (CPT 90847) covered and if so, what is the out-of-network reimbursement rate?
Are extended sessions beyond the first 60-minutes covered (CPT add-on code of 90837) and if so, what is the out-of-network reimbursement rate?
Do any of the CPT codes require prior-authorization?

If yes: do I need to apply for prior-authorization myself and if so, how do I do it?

Do I have an annual or lifetime maximum for psychotherapy services? If so, what is it?
What is my annual deductible and out-of-pocket maximum for out-of-network behavioral health services?

Does this deductible and out-of-pocket maximum a part of or separate from my medical deductible and out-of-pocket maximum?
How much of my out-of-network deductible and out-of-pocket maximum have I met this year?

How do I submit superbills for reimbursement consideration?

How long does consideration take after I've submitted the superbills?
How long does reimbursement take once the consideration is finalized?
Does reimbursement come to me directly or will it go to the facility?

If it goes to the facility, make a request for the reimbursement to go directly to you, as Falcone Institute does not accept insurance reimbursement on our clients' behalf.

How long do I have to submit superbills after the date of service?

Does my policy include speech-language therapy under my medical benefits?
- If yes: Does my policy include out-of-network coverage for a Speech-Language Pathologist (SLP)?
If yes: what is the reimbursement rate for out-of-network SLPs (this will tell you your reimbursement rate)?
*Falcone Institute is not responsible for coordinating with any insurance companies for reimbursement consideration. It is expected that all clients will pay for their services up front and Falcone Institute will provide superbills in a timely manner, when requested.
**Falcone Institute is an approved non-network provider through Tricare West. Coverage is dependent on policy type and referral by a Primary Care Physician.

Since Falcone Institute is an out-of-network provider with insurances, most companies will not share specific policy information with our team members. If you have a question about any of your policy information, please reach out to Carly Diffenderffer (carly@falconeinstitute.com) for guidance. We will do our best to help you understand your policy as best as possible.

No Surprises Act

You have the right to receive a “Good Faith Estimate” explaining how much your medical care 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 before those items and services are provided.

You have the right to receive a Good Faith Estimate for the total expected cost of any health care items or services upon request or when scheduling such items or services.
If you schedule a health care item or service at least 3 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate in writing within 1 business day after scheduling. If you schedule a health care item or service at least 10 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate in writing within 3 business days after scheduling. You can also ask any health care provider or facility for a Good Faith Estimate before you schedule an item or service. If you do, make sure the health care provider or facility gives you a Good Faith Estimate in writing within 3 business days after you ask.
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.

Falcone Institute National Provider Information (NPI) #: 1245771260