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WE ARE AN INDEPENDENT THERAPIST GROUP ORGANIZATION
Staying small allows us to provide tailored care and maintain individual, therapist autonomy; meaning each therapist engages in their own preferred therapeutic methods; and moreover, is free in terms of deciding for themself, and the best interests of their independent clinical practice, the type of pay model to support—i.e., self-pay, insurance, or a hybrid of both. To understand the sum, lets begin with the parts.
Self Pay: This is also commonly called private pay, and means that the bill is paid by you, not an insurance carrier.
Insurance Pay: Insurance agrees to pay the bill, not including copays and deductibles--i.e., monies insurance says you will still need to pay the provider.
In-Network: Means the provider is contracted with an insurance network to take the rates dictated by insurance as the amount due, receive payment on only ‘covered benefits’ stipulated by insurance, and must engage in insurance claim billing practices. However even though there is an agreement with insurance, the patient is still ultimately the one responsible for the bill. Agreeing to take insurance means the provider has contractually agreed to wait 30 to 45 days to receive a reduced payment from insurance as the amount due. Insurance often exceeds this time frame, and so for the sake of our clients, Ei extends this length to 120 days. If after this time insurance has not processed the claim, continues to deny the claim, etc., then the bill is the responsibility of the client.
Out-of-Network: Means the provider is not contracted with the insurance network, and does not have to take the insurance carriers rates or change care parameters to fit within an insurance plan's covered benefits.
Hybrid Pay Model: To support a therapist's independent practice within a group model, it means that our fee schedule must be set the same across all types of pay and across all types of payers--those who are uninsured, insured, and those electing not to use insurance. The reason for this that while Washington state prohibits insurance from using 'most favored nations clauses'--i.e., only reimbursing on the lowest rate offered in a practice--it can not actually stop this from happening, because insurance contracts are protected by priority laws. In other words, even the Insurance Commissioner Office is prohibited from knowing what is in the contracts. Moreover, if there is variation in the rates, then insurance can use what is called a UCR (usual, customary and reasonable) fee rule and will only pay a percentage of the lowest rate offered at a practice, or calculate the fee determined --despite the added billing cost and revenue loss incurred by taking insurance (upwards of 40%, sometimes higher).
However, because we are practitioners who operate a business in order to provide a service, verses a business that hires practitioners to create business, it means we have clinical experience to know that the same fee does NOT fit all. Moreover, we hold a strong value in providing a type of care that is often not possible within the confines of insurance, and so when and where insurance is supported by a therapist, it is a boutique selection, rather than a norm.
To learn more about the different type of pay models your therapist supports, please go to their “About” page.
Self-Pay
Persistence Against the Confines of Insurance
An in-network provider is contracted to offer services under the stipulations set forth by the insurance plan—i.e., limits on procedures, including time, services offered, and mandatory fee adjustments to the provider’s rate. These rates are often set so low that providers must carry large caseloads to offset the costs associated with taking insurance (like need for extensive billing services, thousands of dollars in denied or held-up claims, etc.). You ever wonder why it's hard to find a couples and marriage counselor that takes insurance? The answer is ALL insurance carriers deem this service as only medically necessary if in service to the person who is insured, and because of this, all insurance carriers pay for couples and family sessions at a rate far below even seeing the individual who is insured by themself. This type of counseling though requires not only a greater level of complexity and higher levels of training, but often necessitates longer session times. In 2022 ALL insurance carriers announced extended session codes, across all types of psychotherapy, except groups, would no longer be a covered benefit. So if an hour session ever needs to go longer, insurance will deny the claim or only pay for the minimum session time. Therapy interventions don't work like this though, they are not designed for boxed-time frames, but for effectiveness.
These same limitations though do not apply to out-of-network providers. And so while insurance would prefer clients stay in-network, as this helps them retain the most profit, carriers cannot entice enough skilled providers willing to practice under their network, and so most insurance carriers provide some form of out-of-network benefit so that their customers can get the healthcare services they need--because by law they can not sell you a benefit that is useless (and not having enough providers to cover the needs of the insured creates a useless benefit). 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 fee 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.
Good News: If you have a PPO or POS, this is probably good news for you though, 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.
Affordable Care: We realize most people struggle to afford the full burden of their associated healthcare costs, regardless of pay model used. Fortunately we engage in price transparency, setting our fees within consideration of the CMS (Centers for Medicare & Medicaid Services) schedule and the Fair Health Consumer guide. Moreover, while our fee schedule is the same across all pay models, we still aim to honor the differences among our clients, as well as honor clients who can provide prompt payment so that we can do what we do best--be your therapist, not your biller. This means ALL out-of-network reimbursements go directly to our clients, not to us. We also support cost-saving billing practices, and so whatever we do not have to spend, in time and money, to processing your bill, will be passed back onto you. Lastly, our providers hold pro bono (free) slots. These pro bono spots are often full, but we do maintain a wait list for those seeking this service.
Pay Models Not Supported: We do not provide sliding scale, Single Payer Agreements, nor in-network benefits if we are out-of-network with an insurance carrier. However, we will provide you with information that shows the transparent calculations of our rates, so that you can advocate for better out-of-network reimbursements from your insurance, wherein the rate of reimbursement can reflect a higher percentage of the actual charged rate rather than a figure developed by insurance.
Learn More: Visit our blog site Eastside Insights to learn more about private pay vs insurance models in "Necessity – The Difference of Insurance and Private Pay in Therapy." The action button below can also get you there.