helping Clients with Out-of-Network Insurance Benefits

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Many sought-after Providers are moving away from deplorable insurance practices and becoming exclusively private pay and/or either working a hybrid model with only one or two provider friendly-insurance carriers (if you would like proof of this simply run a therapist search in the two most popular directories--Psychology Today and Good Therapy--and you will see this to be the case).  It means then if you would rather be selective and work with someone of your choosing, or someone who comes highly recommended with a strong reputation for providing quality care, chances are they are private pay, meaning then the most affordable way to accessing these providers is to use your out-of-network benefits.

Insurance though does not make the process of learning about OON coverage easy though, and so ultimately the best way for you to know if you have out-of-network benefits, and what is covered, will from calling and speaking to a benefits representative at your Insurance.  The phone number listed on the back of your insurance card is usually the best number to call to start this process.  However, before you call, please take a moment to review some of the tips and guidance provided below.

Out-of-Network (OON) Benefits: For starters, it is important to know the difference between In & Out-of-Network and types of pay models typically used in Healthcare.  We provide a brief overview of these particulars for you on the "Pay Model" page, which can be accessed through the Getting Started tab at the top of our website.   

If you have a PPO or POS, it means it is likely you have OON benefits, as almost all of these plans cover out-of-network reimbursements with competitive benefits. HMOs, Medicare, and Medicaid unfortunately are the exceptions, and will only provide out-of-network reimbursements for emergency services (we do not provide ER services).  My staff and I have worked on behalf of clients with HMOs and Medicaid numerous times and have yet to see these carriers cover an out-of-network expense. 

Reimbursement Rate:  When seeing a licensed practitioner NOT in-network, insurance will often reimburse for a portion of the out-of-pocket expenses. Typically, this comes in at about 60% of the providers service rate being reimbursed to the client, but it can go as high as 85%; and if a client has a secondary insurance too, then a client may pay almost nothing after receiving reimbursement.  When you call your insurance please make sure to qualify that you are looking to know the reimbursement rate for an Out-of-Network (OON) provider that does not "accept assignment" (meaning the OON provider does not accept In-Network reimbursement rates).

Deductible: Insurance commonly has a deductible that needs to be met prior to receiving reimbursement. If the deductible is large, or perhaps you have an HSA or FSA for such expenses, using your out-of-pocket benefits in this way makes a lot of sense. Knowing this information can help financially plan your care. 

Services: I have compiled a list of the most used and accepted CPT codes in psychotherapy (click tab below). CPT stands for Current Procedural Terminology. It is a medical code used in billing practices and by other accredited establishments to report the medical and diagnostic procedures and services of licensed healthcare professionals. Just because a CPT code exists though, does not mean your insurance will cover this service. When you review your benefits with your insurance agent, please also discuss these CPT codes to see which ones are covered, at what rate, as well as if there are any caps on number of visits or session lengths.   

Diagnosis: Insurance is based on medical necessity, so conditions that are less chronic or acute, or deemed as pre-existing, by your plan, may not be covered. It may behoove you to know what diagnoses are covered up front, or what is deemed as pre-existing. Some practitioners may opt to provide an alternative diagnosis that is covered, so that you can still receive services, but this constitutes insurance fraud and hides the extent of limitations in our healthcare system.