How to Use Insurance with Out Of Network Therapists
How to use your insurance when your therapist is out of network
If you’re looking to start therapy you might have noticed that many of the therapists you want to work with are not in your insurance company’s “network”. This can feel limiting if you want to use your insurance benefits to cover therapy costs. In this article, we will talk about what it means to be “out of network” and how to find out if your insurance will still cover the costs of therapy.
What is the difference between in-network and out of network providers?
In-network providers are therapists who work directly with the insurance company. This means that when you attend your therapy appointments you will only pay your copay up front and your therapist will receive the rest of their payment directly from the insurance company.
Out of network providers do not work directly with the insurance company. This means that when you attend your therapy appointment you will cover the cost of services.
If I go with an out of network provider can I still use my insurance benefits?
In many cases, yes. While your insurance might not pay for the services up front, they might pay you back for the therapy you received out of network. To find out if they cover out of network costs:
Check if your plan covers out of network costs:
It will often say something in your plan like “covers 80% of out of network costs” or “after deductible is met will cover 60% of out of network costs”.
Check your deductible:
Some people have a $0 deductible and others have something much higher. A deductible is the amount you have to spend on your healthcare prior to getting reimbursed for anything. If you have a high deductible, you can often submit your therapy receipts to apply towards the deductible. If you have a low deductible then you might get reimbursement more quickly.
What does all of this mean in simple terms?
Looking at insurance terms can be incredibly confusing, however once you understand what your plan offers it can help you to understand who you can work with and how much it will cost. Read below for two examples of how this works for many of our clients.
No Deductible/ Out of Network Benefits Plan:
Some insurance plans have no deductible Let’s look at an example of how this might play out for the insured person on this type of plan:
You have a no deductible plan and your insurance company covers 80% of out of network costs. You see a therapist of your choice who charges $120.00 an hour and is out of network. At your session you pay $120.00 for the appointment and the therapist provides you with a receipt for services called a superbill. Because you receive 80% reimbursement, you send the superbill to your insurance company and they then send you a check for $96.00. This means your out of pocket cost was $24 which is likely the same or less than your copay.
With a no deductible plan that covers out of network services, you can begin submitting and getting reimbursed as soon as you start therapy appointments (in most cases).
Deductible Plan with Out of Network Benefits:
Some plans have a deductible and will provide out of network benefits after the deductible is met. Here is an example of what that might look like if you’re insured under this type of plan:
You have a plan with a $5,000.00 deductible. After the deductible is met, your plan covers 60% of out of network costs. You have already spent $4,500.00 on medical care this year so you have $500.00 left of your deductible. You see a therapist of your choice who charges $100.00 a session. After each session, you submit your receipt to your insurance company to meet your deductible. After 5 sessions, you’ve met your deductible and any further out of network healthcare costs will be reimbursed to you at 60%. After your sixth session, the insurance company sends you a check for $60.00 meaning you paid $40.00 out of pocket towards your care.
Plans with no out of network benefits
So what happens if you have a plan that offers no out of network reimbursement benefits? This can happen and it might make you feel stuck with the short list of available providers in your network. We have had many clients successfully appeal this by showing that the insurance company does not have enough available therapists in their network or that the insurance company doesn’t provide a specialist in the area that the person needs.
For example, you might be seeking trauma therapy using EMDR with an LGBTQ+ affirmative therapist. As you look at the list of therapists your insurer recommends you might find that no one offers EMDR therapy while also having a specialization in your specific community. Let your insurance company know of this and share with them you’ve found a therapist who does offer these areas of expertise and that you need to work with them.
In the past, we have seen people call their insurance company to let them know that they need to see a specific provider in order to have their condition treated and ask the insurance company to provide reimbursement for these services. You can often be successful taking this path.
Why do people see an out of network therapist?
There are many reasons that someone might choose to see an out of network therapist. These reasons might include:
High level of specialization
Availability for new clients
Privacy concerns (when you work with an in network therapist they have to provide your treatment notes to the insurer, out of network therapists do not do this)
Desire for flexibility (in-network therapists have to get the insurance company to approve the number of sessions you receive, for example)
Preference for a specific therapist
How do I submit my out-of-network costs to my insurance company
There are a few ways that you can submit your out of network costs to your insurance company.
The first step is to request something called a “superbill” from your therapist. A superbill is a detailed receipt that includes all of the information your insurance company needs in order to approve reimbursement.
The superbill will include:
The date of your appointment
The cost of your appointment
The name of your therapist and their license number
The NPI number of your therapist and/or their practice
The EIN number (tax ID) of your therapist’s practice
A diagnosis code if there is a diagnosis
A cpt code (this is the code that tells the insurance company which type of service you received - i.e. individual, couples, or family therapy)
After you have your superbill, you can log into your insurance company’s website and look for the section that includes “claims”. In this section, you are often able to upload the superbill onto their site and submit it for reimbursement. You can then track whether it has gone towards your deductible or reimbursement has been sent.
Insurance companies are notoriously difficult. Because of this, there are companies that can help you to submit your superbill. This means that they do all of the work for you and you just wait for your check. The work they might do includes arguing with the insurance company, making sure the claim isn’t denied for a confusing “administrative” reasons, and putting pressure on the insurer for timely payments.
At A Better Life Therapy, LLC we have partnered with a company called Mentaya. If you work with us and would like to submit your superbills, we can submit them for you through Mentaya and then you just wait for your check (as long as you have coverage)!
You can even use Mentaya’s benefits checker to see how much reimbursement you would get by working with an out of network therapist.
Benefits Checker
Use this benefits checker to see how much you can get reimbursed for working with a therapist on our team.
If you don’t see your preferred therapist listed just click a random name and you will still get accurate information. When you get connected with your preferred therapist you can double check with them using their specific information.
Ready to schedule an appointment? Email info@abetterlifetherapy.com