How to use Out-Of-Network Insurance Benefits to Reduce the Cost of Therapy

Insurance is pretty dang confusing and interacting with insurance companies is something a lot of people want to avoid.

Yet many people have out-of-network benefits for mental health services and don’t use them, because they aren’t fully aware of what those benefits cover. If you’re interested in working with me, I want to help you understand your OON benefits so you can make an informed decision about the financial investment of working with an out of network therapist.  

Many insurance plans, especially PPO plans typically offered through an employer, offer some reimbursement for out-of-network mental health benefits. Some of my clients pay between $40 and $75 per session after reimbursement from their insurance company. Yet many clients believe there is no middle path between seeing an in-network therapist and paying completely out of pocket to see someone out of network. And it’s easy to talk yourself out of making an annoying phone call to an insurance company if you’re already convinced it's no use. 

So if you’re curious about working with me and want to make sure you have all the information about the financial investment in your well-being, let me make it just a little bit easier to make that phone call.  

Grab your emotional support pet/body double/stuffed animal/hoodie and buckle up.

Here is a step-by-step guide to help you learn more about your out-of-network benefits:

1. Grab your insurance card and something to take notes with while you’re on the phone. Take a big breath and maybe grab a snack and something to drink. It helps to not be too hungry, tired, or thirsty when you’re doing something kind of tough.

2. Call the Member Services line, which is typically listed on the back of your insurance card.

3. Explain that you are interested in seeing an outpatient mental health therapist who is not in-network with your plan. If you are interested in working with me, they may want specific information about me and my practice, which you’ll find listed at the bottom of this page.

4. Ask what your out-of-network outpatient mental health benefits are, including your deductible, your out-of-pocket maximum, copay/coinsurance, allowable number of visits, and the allowed amount.
   
   Outpatient: treatment outside of a hospital
   Deductible: amount you need to pay before insurance coverage begins
   Out of Pocket Maximum: typically the amount you are responsible for each year before insurance begins covering services at 100%
   Copayment/coinsurance: sometimes listed as a percentage, sometimes listed as a flat fee. The amount you are responsible for each appointment.
   Allowable # of Visits: how many visits per year that insurance will cover
   Allowed Amount: each insurance has their own fee schedule for services. Often this is lower than a provider’s rates. For example, insurance may only pay $100 for a 45 minute session, even though a provider may charge $150. So if your plan covers 80%, they will reimburse you $80 (80% of the $100), not $120 (80% of $150).
   

5. Ask which billing/service (CPT) codes that they cover. I use the following CPT code for most sessions.
   
   90837 - 53-60 minute individual therapy
   

6. Ask if a referral or prior authorization is required. If so, ask who can make the referral and who needs to complete the request for prior authorization. It’s also important to write down how the referral or prior authorization should be submitted (for example by phone, fax, e-mail, etc)
   

7. Ask how to submit claims for reimbursement. Ask if there is any specific information they need from the provider in order to submit the claim. A claim is a form that you send to your insurance company so you can receive reimbursement for the fee you paid to the therapist.
   
   I have found that one very important part of using out-of-network benefits is asking very specifically how claims should be submitted. Insurance companies often have rules for submitting claims that are hard to track down unless you ask directly.
   

8. Be sure to document your phone call. Write down the name of the person you spoke with and ask for a call reference number. This is useful if there is confusion about reimbursement in the future.

Tips for Calling Insurance:

1. Set aside at least 30 minutes to make this phone call.

2. Have pen and paper ready or an online document to type into so you can write down and organize the information you’re learning.

3. Please ask questions! Many people worry about sounding stupid for needing additional clarification. Try to set those worries aside. You’re entitled to know about and understand your benefits! 

4. If you notice the urge to throw your phone across the room, know that you’re not alone. Maybe even offer a little self-validation “It’s okay to want to punt my phone across the room. It makes sense I want to punt my phone across the room. This is a normal response to an in infuriating reality. I can do this. I can do this.”

5. If you’re up for it, set up a small reward for finishing the phone call. Recognizing and appreciating when  you’ve done a hard or new thing is an important part of learning new skills. 

After you’ve called your insurance to learn about out-of-network benefits, it’s time to take a break.

My Process for Clients using Out-of-Network Benefits:

Before we begin working together, I want to let you know that it’s your responsibility to understand your benefits. That being said, if you have questions about what to ask your insurance, please let me know. I’m happy to help you navigate insurance reimbursement. 

1. We’ll have our session. After the session, I’ll collect my full fee using the credit card you placed on file with me before your intake.

2. Once per calendar month (or more frequently if you specifically request that), I’ll send you a “superbill” which you can submit to your insurance provider. A superbill is a dumb name, because it’s a receipt, not a bill. It’s like a fancy receipt that will include my practice information, your diagnosis, a billing code, and the amount you paid. Insurance will use the superbill to determine if you are eligible for reimbursement.

3. You can choose to submit the superbill to insurance for potential reimbursement. Some people choose not to submit the superbill to insurance for privacy purposes. Diagnosis codes become part of your medical record and some people prefer not to share that information with an insurer. 

Your insurance provider may ask you for the following information about me and my practice:

Provider’s Full Name: Elizabeth Ansley Hayes, LCMHC

Type 1 National Provider Identification (NPI) Number: 1356989842

Practice Address:

301 S Elm St

Suite 517

Greensboro, NC 27401

Phone: 336-814-9960

The billing/service (CPT) codes that I most frequently use:

90837 - 55 minute individual therapy