Accessing Out of Network Health Insurance Benefits
As we head into the fall, many folks are considering accessing mental health therapy to process life, specific events from the first half of the year, or return to therapy as the season cools and we begin to feel the anxiety that some of us face as the sunlight wanes and the temperature drops.
More therapists than ever are choosing to forgo contracting with Private Insurance Companies in the interest of maintaining more control over their practice, income, and to provide options for out of pocket payment, therapy without needing to offer diagnoses or assessment, or flexibility in quantity or length of therapy sessions.
Some therapists have the option to give you something called a Superbill. This is essentially a fancy receipt with all the information your insurance company will need to file a claim to utilize Out of Network Benefits to get reimbursed for some - or even all - of the expense of therapy.
Not all insurance companies offer out of network benefits and not all out of network benefits cover mental health therapy, but it’s worth an ask if you’ve found a therapist you want to work with who isn’t in-network with your Insurance Provider.
Be sure to ask your therapist if they offer SuperBills BEFORE beginning your first session so that you can make the most informed choices regarding who you share your story with and the financial impact of accessing therapy on your finances.
As a therapist, I am currently working to become an in-network provider with public insurance in the State of Oregon, but have no intention of becoming in-network with private insurance for the foreseeable future. I do however want to provide clients with tools, options, resources, and support to utilize out of network benefits for Mental Health Therapy.
I will be creating several different guides and links I offer to clients regarding utilizing Out of Network benefits and other resources recommended by fellow therapists. I hope these are helpful and I welcome emails with any errors in my posting so that I can maintain accurate and adequate tools in this toolbox.
These guides are NOT intended to be all-encompassing nor are they guaranteed to result in reimbursement or coverage, they are merely guides.
First of all, what does out of network really mean?
When you go to therapy, you can pay a few ways.
If you pick a therapist that doesn’t accept insurance at all, you’ll pay their entire fee out of pocket.
Therapists can be considered an “out of network” provider if they offer a SuperBill or offer Courtesy Billing, but you will be responsible for paying out of pocket costs - up to the full session fee - and nearly all insurance reimbursements require your therapist to assign a diagnosis to you in order for services to be deemed “medically necessary” and covered by insurance benefits. Diagnosis isn’t a dirty word, but I’ll save that for another blog post, just know that nearly all of us qualify for a diagnosis for the experiences we are seeking mental health therapy for.
If your therapist takes your insurance plan, they’re in network and you pay a predetermined co-pay up front; your insurance pays the rest to your provider later.
Okay, so how do I figure this out?
The first step I encourage potential clients to take in utilizing out of network benefits is to contact their insurance company (often via phone) and discuss the availability of their Out of Network Benefits. This helps to limit the number of surprises clients experience and helps empower clients to make decisions regarding their healthcare to choose a therapist based on best-fit rather than feel limited to only in-network providers who may or may not have specialty training or experience in the areas of support clients desire or will benefit from the most.
Before contacting your insurance company, you may want to check out the information available to you via any online portals associated with your insurance provider.
Step 0: Check Your Out of Network Benefits Online
On your insurance company website, you can find your Summary of Benefits. While reading through your plan’s summary look for phrases like “out-of-network deductible” and “coinsurance.”
Your out-of-network deductible is how much you have to pay before you can access your out-of-network benefits and be reimbursed. For example: your deductible is $500 and once you pay that amount your insurance company will cover 100% of services. You’ll have met your deductible after you pay $500 and will be eligible for reimbursement.
This means that if you spend $1,000, you’ll be responsible for $500 of that and then your insurance company will reimburse you for all or a portion of the remaining $500. This is normally in the form of a check and is mailed directly to you after you submit a claim. (Note: you will still have to pay out of pocket for your sessions at the time of service.) Your deductible will reset at the beginning of each plan year (not necessarily the calendar year beginning of January 1, so be sure to check) but every out of pocket health expense you have to pay will go towards meeting your deductible.
Coinsurance is the portion of the service fee that you will have to cover. If your therapists’ session fee is $140 and your coinsurance is 50%, you are responsible for $70 and your insurance will reimburse you the other $70. Your coinsurance doesn’t kick in until you reach your deductible so you will have to pay the full session fee until you’ve done so.
If your insurance company has an allowed amount, this means there’s a max that they will pay. Let’s say your allowed amount is $140 for each session, your coinsurance is 50%, but your therapists’ fee is $200. In this case your insurance company will only cover a max of $70 and you will have to pay $130.
Another perspective on Out of Network Benefits (from ZenCare):
Let’s say your out-of-network deductible is $1,000, and your insurance company pays for 100% of services after you meet that amount. That means you’ll have to pay $1,000 out of pocket, after which you’ll have “met your deductible.”
In this scenario, if you spend $1,500 on therapy services, you’ll have to pay $1,000 out of pocket (e.g. $100 at each session for 10 sessions), but a portion of the remaining $500 will be reimbursed to you in the form of a check (mailed to you after you submit your claim). Deductibles reset every calendar year, and any health expense you pay out-of-pocket contributes to meeting it.
Coinsurance: This is the percentage of the service fee that you’re ultimately responsible for paying.
Let’s say your therapist charges $100 per session. If your coinsurance is 25%, you’re only responsible for paying $25. Just remember that this comes in the form of a reimbursement: you’ll need to pay the full $100 upfront, then your insurance will send you a check for $75 after the session, once you’ve met the deductible and submitted a claim.
Some insurance companies determine an “allowed amount,” which caps the session fee that they’ll cover. If your insurance has determined $100 is their “allowed amount” per session, at a 25% coinsurance rate, your insurance company will still only reimburse you up to $75, no matter what the therapist’s session fees are. In other words, if your insurance has an allowed amount of $100 but your therapist’s session fees are $200 per session, you won’t get reimbursed more; you’ll still be reimbursed $75, and will be ultimately responsible for $125.
Step 1: Call Your Insurance Company to Verify Benefits & Reimbursement Processes
When inquiring about out-of-network mental health benefits with your health insurance company, it's important to communicate clearly and gather all the necessary information. Here's a step-by-step guide on how to do so:
Gather Information: Before reaching out to your health insurance company, gather all relevant information about your current policy. This includes your policy number, the name of the insurance company, and any documentation you may have received when you enrolled.
Contact Customer Service: Call the customer service number provided by your health insurance company. This information is usually found on your insurance card, the company's website, or any communication you've received from them.
Be Prepared to Identify Yourself: When you call, you'll likely be asked to verify your identity for security purposes. Have your policy number, date of birth, and other identifying information ready.
State Your Purpose Clearly: Explain that you're calling to inquire about the out-of-network mental health benefits available under your policy. You might say something like: "I'm calling to understand the out-of-network mental health benefits included in my policy."
Ask Specific Questions: Make sure to ask specific questions to gather the information you need. Here are some questions you might consider asking:
Can you explain the coverage details for out-of-network mental health services?
What percentage of the cost will be covered by the insurance for out-of-network mental health visits?
Is there a deductible or out-of-pocket maximum that applies to out-of-network mental health services?
Do I need to get pre-authorization or submit any documentation before seeking out-of-network mental health care?
Are there any limitations on the number of sessions or types of therapy covered?
How much of my deductible has been met this year?
What is my out-of-network deductible for outpatient mental health? (Outpatient means treatment outside a hospital.)
What is my out-of-network coinsurance for outpatient mental health?
Do I need a referral from an in-network provider to see someone out-of-network?
How do I submit claim forms for reimbursement? (Claims are forms that are sent to your insurance company to receive reimbursement for sessions you paid for out of pocket.)
Understand Costs and Reimbursement: Ask about how reimbursement for out-of-network services works. Will you need to pay the full cost upfront and then get reimbursed by the insurance company, or will the provider bill the insurance directly?
Take Notes: While on the call, take notes on the information you receive. This will help you remember the details later and have a record of what was discussed.
Request Documentation: If the representative provides information verbally, ask if they can send you a summary of the benefits in writing. This way, you'll have a reference to refer back to.
Clarify Anything Unclear: If there's anything you don't understand, don't hesitate to ask for clarification. It's important to have a clear understanding of your benefits.
Thank Them and Follow Up: After the conversation, thank the representative for their assistance. If you need to take any further steps, such as seeking pre-authorization or finding an out-of-network provider, make sure you understand what's required and the necessary timelines.
Remember that insurance policies can be complex, so it's okay to ask questions until you have a full understanding of your benefits. This will help you make informed decisions about your mental health care.
Step 2: Access Therapy and Pay for Sessions
When utilizing Out of Network benefits you’ll likely need to pay your therapist the entire session fee at the time of service, and depending on your specific plan, your insurance company will mail you a check to reimburse a portion of that cost.
Some therapists have options to submit Out of Network Claims on your behalf and may establish their own policies and practices such as “Balance Billing” where the therapist will submit an out of network claim on the client’s behalf and the client will be responsible for a portion of the billed amount - depending upon the Insurance Company’s practices and policies. Other therapists may offer options to submit SuperBills on behalf of clients and have reimbursement sent directly to the client through various apps or billing services.
Step 3 : Ask your Therapist for / Receive a SuperBill
Once you get your Superbill from your therapist you can then use it to submit a claim for reimbursement following the processes outlined in the information you learned when you contacted your insurance company.
Step 4: Submit the SuperBill to your Insurance Company Directly or Via an App
There are several ways to file a claim for reimbursement. Some insurance companies require you to do it through their website but you may also be able to use an app. There are a few options listed below.
Reimbursement apps will help you through the process of filing claims, though they may charge a small fee.
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Commonly Used Apps to file Out of Network Benefit Claims
TheSuperBill - clients can check out of network benefits with TheSuperBill, submit SuperBills, track claims, and receive reimbursement, information about out of network billing, and support from TheSuperBill regarding claims if there are bumps along the road.
Reimbursify - After clients receive a Superbill, they can submit SuperBills via Reimbursify, track claims, and receive reimbursement, information about out of network billing, and support from Reimbursify as needed about how to reach out to the Insurance Company
Thrizer - Thrizer is similar to Reimbursify and TheSuperBill and is an emerging app that works in similar ways.
I have not utilized these apps - yet - so I am not able to comment on how they work, but want to share these as options for current and prospective clients.
For other resources regarding Out of Network Benefits, check out these popular blogs about this topic;
https://blog.opencounseling.com/out-of-network-therapist-tips/
https://www.zocdoc.com/blog/what-does-it-mean-to-get-an-out-of-network-therapist/
These guides are NOT intended to be all-encompassing nor are they guaranteed to result in reimbursement or coverage, they are merely guides.