how Reimbursement really works
Searching for a therapist can be difficult—even tedious. There are many factors to consider, including cost. In your search, you may find yourself coming across therapists who do not accept insurance. You may see descriptors such as:
Private pay
Cash pay
Out-of-network (OON)
Fee for service
These terms refer to the same concept. Many therapists, myself included, choose not to accept insurance. I want to be clear that there are many well-qualified and wonderful therapists who accept insurance! But they aren’t your only options.
My goal for this article is to help you get reimbursed by your insurance for out-of-network mental health services. I am not an insurance expert, but this is my best understanding of the process. Hopefully this knowledge will allow you to focus on finding the right fit instead of settling for the right price.
Where To Start
Many insurance plans offer out-of-network benefits that can help cover the cost of therapy. Reimbursement rates can vary significantly based on the insurance provider and plan agreement, so it is a good idea to get to know your specific benefits package. Contacting your insurance provider directly is the best way to get personalized information. Here are some questions you may consider asking:
Do I have out-of-network benefits for outpatient mental health services through telehealth?
What is my out-of-network deductible for outpatient mental health?
How much of my deductible has been met this year?
What is my out-of-network coinsurance for outpatient mental health?
Do I need a referral from an in-network provider (like my primary care provider) to see someone out-of-network?
How do I submit claim forms for reimbursement?
Once these questions are answered, you should have a sense for what percentage of the therapy costs will be reimbursed. For example, your insurance provider may inform you they are willing to reimburse 70% of the total out-of-network service fee.
Next Steps
With this information in hand, you will be able to choose if you prefer to see an in-network or out-of-network provider. If you choose to move forward with an out-of-network provider, here are the next steps:
Find the right therapist
Pay the full service fee up front at the time of your therapy session
Ask your therapist for a special invoice called a superbill
Submit the superbill to your insurance
Receive your reimbursement check
Let’s go into a little bit more detail, one by one.
Find the right therapist
Finding the right therapist is a process. Don’t lose hope if you don’t find a great connection on the first try! For more information on how to find a therapist and what to look for, check out this blog post.
Pay the full service fee up front at the time of your therapy session
Every therapist is different, but most expect payment at the time of session in the form via credit card, cash, or check. In my practice I accept online payments from all major credit cards as well as HSAs and FSAs.
Ask your therapist for a special invoice called a superbill
This special invoice will be provided to you by your therapist. A superbill is a document that includes provider information, the dates and times of your sessions, the type of session that took place, the cost of your sessions, and the applicable diagnostic codes. You can request a superbill after each session, once monthly, or at a different frequency of your choosing. For my clients, the superbill is provided electronically through a secure client portal.
Submit the superbill to your insurance
This part can sound intimidating, but is often quite simple! Most clients are able to submit their superbills online by logging into their insurance account and uploading the needed documents.
Receive your reimbursement check
Hooray! You’re getting your money back! Reimbursement usually comes in the form of a check from your insurance provider, and is often processed as soon as your superbill is reviewed.
Final Thoughts
I recognize it can sometimes be quite a shock to see the private pay prices that therapists list. I also recognize it takes some degree of financial stability to be able to spend the money on sessions up front and wait for reimbursement to come through. For some people, the difference in cost may be a very real barrier to care, so it is important to know the numbers you are truly working with. I don’t take this lightly, which is why I always save room on my caseload for reduced fee sessions.
Consider this, what if the price difference between in-network and out-of-network was ultimately only ten dollars? For example, your co-pay for an in-network provider may be $40, while for an out-of-network provider your total amount spent after reimbursement may be only $50. In this scenario, perhaps you would feel the prices are comparable, freeing you up to choose the provider that feels like the best fit for you.
I hope this article has helped to make an intimidating process seem more manageable. If you have questions or concerns, please reach out and let me know! Wherever you’re tuning in from, thank you for being here and take good care.
With love, HLP
Disclaimer: The information in this blog is provided for educational and informational purposes only. It is not intended to be a substitute for mental health care nor a recommendation or endorsement for any particular treatment plan, organization, provider, professional service, or product. The information may change without notice. No claims, promises, or guarantees are made about the completeness, accuracy, currency, content or quality of information linked. You assume all responsibility and risk for any use of the information.
