"The choices we make in healthcare, shape healthcare."

Eastside Insight supports a Private Pay Model. Meaning services are not limited to or dictated by Insurance Companies. 

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 larger and larger caseloads to offset the costs associated with taking insurance (like need for extensive billing services, etc.). You ever wonder why its hard to find a couples and marriage counselor that takes insurance? The answer is ALL insurance carriers deems this service as only a medically necessary if in service to the person who is insured, and because of this, all insurance carriers pay for couples and family session at a rate far below even seeing the individually insured by themselves. This type of counseling requires not only a greater level of complexity and higher levels of training, but often necessitates longer session times—which just this year ALL insurance carriers announced would be codes they would not cover (these codes are known as extended session time).

These same limitations though do not apply to out-of-network providers. And so while insurance would prefer clients stayed in-network, as this helps them retain the most profit, carriers cannot entice enough skilled providers willing to practice under their umbrella, and so most insurance carriers provide some form of out-of-network benefit so that their customers can get the healthcare services they need. 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. 

However, health insurance, while a necessity, is also a huge, for-profit business, and so these reimbursements can be much lower as well. It all just depends on the insurance plan, as all rates, even out-of-network reimbursements, are backed by special laws designed to protect insurance (rather than the consumer or provider) through clauses known as ‘propriety information.’ Meaning carriers never have to post their rate schedules and can change their covered benefits and associated costs at will. Providers, on the other hand, are required by law, to engage in fair consumer practices of making their fee schedules public. 

If you have an PPO or POS, this is probably good news for you though, as almost all these plans cover out-of-network reimbursements with competitive benefits. HMOs, unfortunately are the exception, and will only provide out-of-network reimbursements for emergency services. My staff and I have worked on behalf of clients with HMOs numerous times and have yet to see an HMO cover an out-of-network expense.

Financial Hardship: We realize most people cannot afford the full burden of their associated healthcare costs, and for this reason, we set our fees to be within range of the CMS (Centers for Medicare & Medicaid Services), meaning our rates are the lowest among service providers in the area. Moreover, we offer generous private pay and out-of-network discounts on nearly all services to help further absorb these costs. And lastly, our providers also hold pro bono (free) slots. These pro bono spots are often full, but we do maintain a wait list for those seeking this service. 

Help with Out-of-Network Benefits: If you would like to help figuring out the best course to using your out-of-network insurance benefits, please select "Insurance Benefits" under the "Getting Started" tab.  Here you will find detailed information regarding this process.  You can also call our office and speak to a live person at any time to get more information.

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.