helping Clients Access 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 this process easy, so please read through all of the guidance below prior to making your call to insurance.  Usually the best number to call is the one located at the back of your insurance card.

Out-of-Network Benefits: Does your insurance plan offer out-of-network benefits?

Reimbursement Rate: Fee-for-service reimbursement is often 80% for in-network, and 60% for out-of-network, but every plan is different, so please ask for the reimbursement rate specific to your plan. 

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.