“Your health is an investment, not an expense.” — Unknown
Let’s get down to the nitty gritty. How much is therapy going to cost me? Specifically, how much is therapy going to cost me when I cannot use my in-network benefits through my insurance?
You will find that many therapists, including myself, do not contract with insurance, and therefore millions of consumers who have insurance benefits cannot utilize their in-network benefits. Don’t panic just yet…Just because your therapist is not in-network, does not mean that you cannot use your insurance plan’s out-of-network benefit to help pay for your therapy services (this applies to most other medical services as well). For patients who do not have insurance, or whose insurance does not have an out-of-network benefit, full cash pay is always available. Patients who contribute to a FSA or HSA can also use those resources to fund their therapy services.
How do out of network benefits work you ask? Out-of-network benefits are billed when you use a provider that is not contracted with your health insurance. You will pay the full amount of your providers cash rate at the time of service. You will then submit the claim to your health insurance company (if you are a patient of my practice, I will help support you in this process). After submitting the claim to your health insurance, you will be reimbursed for the remaining balance that the plan covers (the difference of the coinsurance). It is important to know that PPO plans typically ONLY cover out-of-network after your deductible has been met. See example below.
- 20% co-insurance, after $1500.00 deductible, therapist charges $150 per session. After you meet your $1500.00 deductible (through various medical costs), your plan will reimburse you $120 per session for each therapy claim submitted. You will spend $30 per session once reimbursed by your insurance.
- Most plans have deductibles and deductibles must be met in full (by the patient paying for services at full cost) prior to insurance kicking in.
- $1500 plan deductible. Patient enters therapy with $0 deductible being met. Patient pays $150.00 per session for a total of 10 sessions (assuming no other medical services are provided concurrently). Once the patient has paid $1500 total out-of-pocket, co-insurance kicks in and reimbursement claims can be submitted.
- HMO and EPO plans typically do not reimburse out-of-network costs
- Most plans have deductibles and deductibles must be met in full (by the patient paying for services at full cost) prior to insurance kicking in.
Questions to Ask your Insurance When Contacting to Inquire About Out-of-Network Benefits
- What is my out-of-pocket responsibility?
- What is my out-of-network deductible for outpatient mental health?
- How much of my deductible has been met this year?
- What is my reimbursement rate for …?
- 90791 – Initial Assessment
- 90834 – Individual Therapy 45-53 Minutes
- 90837- Individual Therapy 53-60 Minutes
- Additional codes may be billed based on the services provided by your individual therapist
- What is my reimbursement rate for telehealth services?
- Does my plan cover telehealth services?
- Do I need a referral from an in-network provider to see someone out of network?
- Do I need any other prior authorization to receive these benefits?
- How do I submit claim forms for reimbursement?
- Is there a deadline for my reimbursement?
- Is there anything else I need to do?
***Disclaimer***
ALWAYS check with your insurance prior to initiating services with an out-of-network provider if you wish to be reimbursed.
