Frequently Asked Questions about Out-of-Network Benefits
So many therapists now are not in-network with insurance. People have a lot of questions about why this is, what are the benefits to you as a client, and how you can use out-of-network benefits. I thought I’d answer some of those questions here today.
What is the difference between in-network and out-of-network?
Not all providers take all insurances! If a provider is in-netowrk, that means they have entered a contract with the insurance company agreeing to a specific fee for each service provided and that they will submit all claims to the insurance company. If you have an in-network provider, all you are responsible for is a deductible, copay, and/or coinsurance (depending on your specific plan).
When a provider is out-of-network, that means they do not have an agreement with the insurance company. While differnet providers handle this in different ways, generally the provider will bill you their full fee directly and then provide you with a superbill that you can turn in to your insurance for reimbursement (if you have out-of-network benefits).
Why doesn’t my therapist take my insurance?
There are many reasons some therapists do not take insurance, and I could write an entire post going in-depth into each of them. Some of the main reasons are:
Insurance requires a diagnosis, and only allows us to bill for certain ones. This comes up in couple’s counseling a lot. Let’s say you want to work on communication skills with your partner and you decide to get counseling to help. Communication struggles are not a mental health diagnosis, and insurance likely wouldn’t pay anyway. Others have diagnoses they don’t want on their record for a vareity of reasons; I see this with my autistic clients a lot. But in order to bill insurance, we have to provide a diagnosis.
Insurance can dictate treatment. Some plans have limits to how many sessions you can have during a certain time frame (like a year), or may not allow for multiple sessions in a week when needed. Also, insurance does not pay for sessions over 60 minutes, yet some clients genuinely need 90 minutes or more (we see this often with EMDR or even crisis sessions).
Insurance companies can request an audit from the therapist and review all of the clinical file. When this happens, they are looking to ensure the therapist is providing therapy, however, in order to complete an audit, they have to review the therapist’s notes. As a client, by using insurance, you are allowing the insurance company to audit files- your therapist can not refuse due to confidentiality.
What do I do if I want to use my out-of-network benefits?
First of all, you need to check to see if you have any OON benefits. While many plans do, there are also some that don’t provide any OON reimbursement. You have a few ways to get this information:
Probably the easiest is to look at your insurance card. Some have lines on them for INN and OON, followed by the individual and family (if applicable) deductible.
You can call the phone number on the back of your card and ask about OON coverage.
You can log in to your insurance portal and find the information there. This can sometimes be tricky to find, so be sure you are looking at out-of-network coverage.
The first thing you will need to do is either call your insurance company or log on to your online portal and check. Every plan is going to look different, so you may have to dig for a specific tab.
Some additional information you want to get from your insurance company if you do have OON benefits:
What is my OON deductible? This is the amount you will have to pay before your insurance will reimburse you anything, and is separate from your in-network deductible. You will also want to check on mental health benefits. For some plans, mental health coverage is rolled in with medical, but for some they are separate. And some plans have a mental health “carve out,” which is where a different plan manages mental health benefits. Be sure to get clarification.
How much coverage do I have once I meet my OON deductible? This number is usually a percentage and less than your INN coverage.
For example, and these numbers are all completely made up, a plan could have the following coverage:
INN $2000 deductible, then covered at 80%
OON $6000 deductible, then covered at 60%
In this case, if you are seeing an in-network provider, you will have to pay upfront for all medical costs up to $2000. This generally includes all providers you see- primary care, mental health, specialists like an allergist or endocrinologist. Once you have met your deductible (paid a combined amount of $2000), your costs are covered at 80%, which means for all visits you will pay 20% of what your insurance contracts with that specific provider.
If you are seeing an out-of-network provider for this same example, you have to pay upfront for all costs up to $6000. Once you have met that deductible, you will still pay your provider in full for services, but you can submit a superbill to your insurance and they should reimburse you 60% of the costs.
What is a superbill and what do I do with it?
A superbill is a form that your provider can give to you with all the information your insurance needs to reiumburse you for services. It’s similar to a receipt, but also has additional information that your insurance company needs, such as a diagnosis (which is required for insurance to reimburse) and a CPT code (this basically tells the insurance what the actual service was, and for many therapy services, how long you met with your provider). Again, every plan is different, but most plans have a place to submit a superbill through their client portal, or somewhere you will need to mail, fax, or email the form. Once they have received it, processed it, and approved it, they will send reimbursement directly to you if you have met your OON deductible. If you have not met your OON deductible, you’ll still want to submit these, as only claims that have been submitted can count towards your deductible.
One huge caveat to keep in mind is that ultimately, your insurance company is the one who determines if they are reimbursing for a service and if it qualifies under your specific plan. No therapist, medical provider, office staff member, HR plan administrator, or anyone else can guarantee any type of coverage or reimbursement, so it is imperative to get all information directly from your insurance company and your specfic plan.
Hopefully that clears up many of the questions that you have about using your out-of-network benefits. If you are ready to learn more about therapy or an autism and/or ADHD evaluation, click here to schedule a free 20 minute consult.
