Often, the first question we are asked by a prospective patient is, “Do you take my insurance?” The answer is, we see patients with any insurance. However, we may not be “in-network” with your insurance company. Many patients call around looking for someone who is “in-network” with their insurance company. However, most do not realize that seeing an out-of-network provider may actually cost comparably to seeing an in-network provider (more on that below!)
What Does “In-Network” Mean?
An in-network provider has a contract with your insurance company and has agreed to only perform services under a contracted rate. The patient often owes a co-payment (“co-pay”) and then must pay the remaining balance between their copay and the provider’s contracted rate. However, many people have high-deductible plans which require them to pay for all services in full BEFORE insurance covers anything.
Example: A provider has a rate of $200 per session. Based on the providers in-network contracted rate with Aetna, a therapy session is $100 ($50 copay and $50 remaining balance). The patient has a $2,500 deductible. Based on this in-network contracted rate, the patient must pay $2,500 to meet their deductible before insurance covers anything. This means that after the patient pays $2,500 for 25 sessions at $100 each, Aetna will start to cover sessions. If therapy sessions are biweekly, the Aetna deductible will be met after 50 weeks and then Aetna will begin to pay. In this example, Aetna would pay for the one session left in the calendar year before the deductible resets and the patient is responsible for the out-of-pocket payments again.
What does “Out-Of-Network” mean?
Out-of-network (OON) means that the provider is not “in-network” with your insurance company and they do not have a contract developed. However, based on your specific plan, the insurance company may reimburse you, to make services at our office more affordable for you. All of our providers meet the licensure, training, and education requirements necessary for out-of-network reimbursement coverage.
We encourage you to call your insurance company and ask the following questions:
Do I have a deductible and if so, how much have I met? A deductible is how much money you have to spend before the benefits of your specific insurance plan kick in. After you “reach” or “meet” your deductible, you will be eligible for your benefits/coverage.
What is my out-of-pocket maximum?: An out-of-pocket maximum is the most amount you will spend out-of-pocket on any copays, coinsurances, deductibles, etc. Once this amount is reached, insurance pays 100% of your covered benefits. *Out-of-pocket maximums are often very high; Marketplace plans are upwards of $17,400 for families!
What is my percentage reimbursement for seeing an out-of-network, outpatient, behavioral health provider?: Your amount of reimbursement for seeing an out-of-network provider is the percentage an insurance company will cover for your out-of-network spending, generally after you meet your deductible.
Why do you not accept my insurance?
A number of flaws exist with the insurance system and the way it currently works, which causes the vast majority of psychologists to not contract with insurances as in-network providers. While we want to make this experience as cost-effective for our patients as possible, here are a few reasons why we may not be in-network with your particular insurance company: *This list is not exhaustive, but provides a glimpse into why working with an out-of-network provider may actually empower you to feel more independent and more in control of your care, without the limitations of being bound by an external third party.
- Insurance companies do not always accept applications and this does not mean the provider is not qualified or great at their skill. Sometimes, a certain zip code is “oversaturated,” so the provider cannot apply to accept that insurance in-network, even if they wanted.
- Insurance companies do not always pay on time (or at all), depending on whether they consider the service to be “medically necessary” for the patient and often require pre-authorization. They also often limit the amount of sessions a patient is allowed. We do not consider it appropriate for an insurance company (who has never met the patient) to tell providers (who are experts in their fields) how many and what type of services you should have.
- The contracted rates that providers are reimbursed from insurance companies are low.
- To receive payment from insurance companies, providers need to assign you a diagnosis. Many seek psychological services for general life stress or circumstances that do not otherwise fall under a formal “mental illness” or “diagnosis.” You may also respect the general notion of privacy and you may not want a diagnosis on your permanent health record forever. Note: superbills require diagnoses be listed.
- Often, copays and deductibles are quite high and make the cost associated with seeing an out-of-network provider more reasonable, if not similar. High deductible plans result in patients paying out-of-pocket for months (sometimes almost the entire year!) before any insurance benefits even kick in.
- Using an in-network provider generally makes it much harder to choose your own provider and causes you to be limited by who accepts your insurance in-network, has availability, and has specific expertise in your area(s) of concern.
- If you switch employers, or your employer switches insurance providers, you may be vulnerable to needing to switch your provider after gaining trust and building a relationship, only to have to start over with someone new.
How do I get reimbursed for services with an Out-Of-Network provider?
After every therapy session at our office (or at the conclusion of testing), we will provide you a “superbill” that can be submitted to your insurance company in attempt to receive reimbursement. A superbill provides the insurance company your personal information, appointment information, and fees paid. The insurance uses the information on the superbill to determine what they may reimburse you. After the superbill claims are processed and if approved, the insurance company sends you a check directly!
There are companies (e.g., Reimbursify) that can assist with the out-of-network reimbursement process for you as well if you are interested.
Example:
A family is quoted $3,000 for their sons autism testing. They have a BCBS insurance plan with a $2,500 in-network deductible and 30% reimbursement for seeing an out-of-network provider at our office, based on their out-of-network benefits.
Choosing an in-network provider: Based on the providers in-network contracted rate with BCBS, testing now totals $2,600. Based on this in-network contracted rate, the billable charges of testing totals $2,600. The family must meet their $2,500 deductible before insurance covers anything after. The family pays the office $2,500 and the insurance pays the office the remaining $100 due. The family ends up paying $2,500 total out-of-pocket for the testing.
Choosing an out-of-network provider: Based on the providers out-of-network status with BCBS, testing remains $3,000. The family pays the office $3,000 but after submitting their superbill to BCBS, is reimbursed by BCBS for 30% of their costs and receives a check back from BCBS for $750 after testing is completed. The family ends up paying $1,750 total out-of-pocket for the testing.
*It is important to note that every individual plan varies (even within the same insurance company.) Knowing your benefits (individual and family deductibles, coinsurance, out-of-network reimbursement options, etc.) will assist you in making an informed decision about seeking care with an OON provider.