A note about Insurance

We are considered Out-of-Network for health insurance / managed care plans and fees are due directly to our practice at the time of service.  Depending on your benefits, after you file a claim with your insurance plan, they will directly reimburse you at their standard rates.

We make it easy for you to file a claim to get reimbursement from your plan, by providing you with a "Superbill" which you submit directly to your insurance provider for reimbursement. The Superbill is an itemized receipt that also lists out the diagnostic codes that insurance companies need to process the claim.

Almost all plans reimburse participants, depending on the plan & coverage options. In some cases (e.g., if your insurance provider lacks network adequacy of In-Network providers actively taking patients) they may be legally obligated to provide you Out-of-Network coverage even if your policy does not carry it.

I encourage you read the 4-Step Guide to Maximize Out-of-Network benefits, and to contact your health insurance plan to verify their policies

4-Step Guide to Maximize Out-of-Network benefits for Mental Health

Most Insurance plans offer Out-of-Network coverage for Mental / Behavioral health. Verifying your specific Out-of-Network benefits before starting treatment ensures you understand your coverage and both your and your insurance company’s financial responsibilities.

Here's a detailed 4 step guide to help you maximize Out-of-Network benefits.

Step 1: Review Your Insurance Plan Documents 

You can find your plan's Summary of Benefits and Coverage through your insurance provider’s portal, or ask your HR department. This document outlines your insurance plan’s coverage, including Out-of-Network benefits for Mental / Behavioral Health. If your plan covers Out-of-Network benefits for Mental / Behavioral Health, confirm the following:

  • Deductible for Out-of-Network Coverage
    Review if your plan has a separate Out-of-Network deductible, which is the amount you need to pay for your health care services before your insurance plan starts to pay.

  • Coinsurance for Out-of-Network Coverage
    Coinsurance is a percentage of the cost of your healthcare service that you pay after meeting your deductible. Find out what the Coinsurance percentage is (e.g., 20%, 30%, etc.) for Out-of-Network Mental / Behavioral health. (Some plans, like HMOs or EPOs, may not cover Out-of-Network care except for emergencies. See below for further details on choosing a plan with the best Out-of-Network benefit options.)

  • “Maximum Out-of-Pocket” feature
    If your plan has a “Maximum Out-of-Pocket” feature, that is a great benefit! Find out what the dollar amount is, because that will be maximum you will have to pay for Out-of-Network care per year - once your payments exceed that amount, the insurance plan may cover you at 100%.

Step 2: Contact Your Insurance Company to verify / validate

Call the number on the back of your insurance card and ask to speak to a Customer Service representative about your Out-of-Network coverage / benefits for Mental Health or Therapy Services.

  • Ask these 7 questions about your Coverage for Out-of-Network Therapy

    • Verify the Out-of-Network Deductible
      Note down how much your Out-Of-Network deductible is before the insurance starts covering therapy.

    • Verify the Coinsurance rate
      Note down the percentage of the cost of each doctor visit that you will be responsible for (after meeting your Out-of-Network deductible).

    • Verify the plan’s UCR rates
      Ask and note down what their Usual, Customary, and Reasonable (UCR) rate is for the following Procedure Codes (also known as CPT or ICD codes): 90791 and 90837. Some plans reimburse a percentage of UCR fees, which may be lower than the doctor’s actual charge.

    • Pre-Authorization Requirements
      Ask if you need to obtain “pre-authorization for Out-of-Network therapy services” and if so then how frequently you have to obtain it. Failing to get pre-authorization can result in claim denials.

    • Check for Reimbursement Limits
      Some insurance companies cap how much they will reimburse per therapy session. For example, if your doctor charges $250 per session for procedure code 90837, but the plan’s UCR rate for procedure code 90837 is $200 and the Coinsurance is 30%, you will be reimbursed $140 (30% of $200).

    • Pre-Authorization Requirements
      Ask if you need to obtain “pre-authorization for Out-of-Network therapy services” and if so then how frequently you have to obtain it. Failing to get pre-authorization can result in claim denials.

    • Ask About Maximum Number of Sessions
      Confirm if there is a limit to how many therapy sessions are covered annually for Out of-Network providers. Some plans may have caps such as 20 sessions per year, or require ongoing pre-approval for additional sessions.

  • Ask about Filing Claims for Out-of-Network Therapy

    • Claims Process
      Since Out-of-Network providers don’t file claims on your behalf, you will need to submit your reimbursement claims yourself to your insurance company. Confirm the process for submitting reimbursement claims to your insurance company.

    • Documentation Requirements
      Ask the insurance company what documentation they require from you to file a claim for reimbursement of therapy or Medication management. Typically, you will need: 

    • Superbill from your doctor (an itemized receipt listing the therapy/medication services, cost, and provider details).

    • Diagnosis codes (CPT or ICD codes) that justify the need for therapy/medications.

    • Time Limits for Submitting Claims
      Verify any deadlines for submitting claims to ensure you don’t miss reimbursement opportunities. 

Step 3: Estimate Your Costs and Reimbursement 

  • Calculate Potential Reimbursement
    After understanding the UCR rates and Coinsurance percentages, you can estimate how much you will be reimbursed after meeting your Deductible. Here’s an example that assumes the doctor charges $250 per session; and your insurance plan UCR is $200 with Coinsurance rate of 70%:

    • Doctor’s charge (you pay the full amount for the service to the doctor): $250 per session

    • Insurer’s Usual and Customary Rate (UCR): $200 per session; Coinsurance percentage: 70%

    • Insurance reimbursement: $140 per session ($200 UCR x 70% Coverage rate)

    • Your Net Cost: $110 [$250 (upfront to the doctor) minus $140 (insurance reimbursement)]

  • Factor in the Deductible
    If you haven’t met your out-of-network deductible, you’ll need to pay the full cost of treatment sessions until you reach it. Example: If your out-of-network deductible is $1,000, you must pay the first $1,000 in treatment fees before the insurance begins reimbursing the rest. 

Step 4: Keep Detailed Records of Your Claims 

  • Track Your Payments and Reimbursements
    Keep a record of all therapy sessions, medication management visits, receipts, and insurance submissions. This helps you track when you’ve met your deductible and ensure you receive proper reimbursement. 

  • Follow Up on Claim Status
    Monitor your claims to ensure timely reimbursement.

  • If a claim is denied
    Review the  Explanation of Benefits (EOB) and contact your insurance company for clarification or file an appeal.
    If you are persistent, oftentimes appeals are successful, especially if your plan lacks enough active in-network providers.

Choosing an Insurance Plan with Out-of-Network Benefits

Choosing the right insurance plan that includes strong out-of-network benefits can provide flexibility and access to a broader range of healthcare providers. Here’s a detailed guide to help you make the best choice during open enrollment: 

Step 1: Understand Different Plan Types 

Preferred Provider Organization (PPO): 

  • Best for Out-of-Network Benefits: PPOs generally offer the most robust Out-of-Network coverage.

  • Flexible: You can see any healthcare provider without a referral.

  • Higher Premiums: Expect higher monthly premiums, but with better out-of-network reimbursement.

Point of Service (POS):

  • Moderate Flexibility: POS plans allow you to see out-of-network providers, but only with a referral from your primary care physician (PCP). 

  • Lower Premiums: Compared to PPOs, POS plans may offer lower premiums, but at the cost of requiring referrals and having stricter network rules. 

Health Maintenance Organization (HMO) or Exclusive Provider Organization (EPO): Limited Out-of-Network Coverage:

  • HMO/EPOs offer limited to no Out-of-Network care unless it’s an emergency or if their In-Network providers do not have capacity to take on new patients without a months-long wait.

Step 2: Assess Out-of-Network Coverage 

Reimbursement Levels (Coinsurance): 

  • PPO and POS plans typically cover 50-80% of Out-of-Network costs after the deductible is met. Look for plans with higher reimbursement rates (e.g., 70-80%) for Out-of-Network care. 

Deductibles: 

  • Separate Deductibles: Many plans have a separate Out-of-Network deductible, which is usually higher than the In-Network deductible. Make sure to factor this into your decision. 

  • Example: If the In-Network deductible is $1,500, the Out-of-Network deductible might be $3,000 or higher. You must meet this before your insurance begins to cover a portion of Out-of-Network care. 

Maximum Out-of-Pocket: 

  • Some plans may have a separate maximum Out-of-Pocket for Out-of-Network care, or they may exclude Out-of-Network expenses from counting toward the overall limit. Ensure the plan’s “Maximum Out-of-Pocket” is reasonable for Out-of-Network services to protect you from excessive medical bills. 

Step 3: Consider Balance Billing and Usual, Customary and Reasonable (UCR) Fees 

Balance Billing: 

  • What insurance plans consider Usual, Customary and Reasonable (UCR) fees are often lower than the market rate and the actual fees that Out-of-Network providers can charge. The provider may then "balance bill" you for the difference between their charge and what the insurance pays. 

  • Some insurance plans may offer protections against balance billing, so check for this feature when comparing options. 

Usual, Customary and Reasonable Fees: 

  • Insurance companies reimburse based on what they deem “reasonable and customary” for Out-of-Network services in your area. If a provider’s charges exceed this amount, you may have to pay the difference. 

  • Look for plans that define Usual, Customary and Reasonable fees favorably, such as those that reimburse based on a percentage of the provider’s actual charges rather than a lower fixed rate. 

Step 4: Supplemental Insurance for Out-of-Network Coverage 

Gap Insurance: 

  • Some employers cover gap insurance plans that help cover the difference between Out-of-Network charges and what your primary insurance pays. These plans can be a valuable option if you expect to use Out-of-Network services often. 

Health Savings Account (HSA): 

  • If you choose a high-deductible health plan (HDHP) with Out-of-Network benefits, consider pairing it with a Health Savings Account (HSA). Contributions are tax-free and can be used to pay out of-pocket medical expenses, including Out-of-Network costs. 

Step 5: Ask for Real-Life Examples and Support 

Speak with HR or Benefits Advisors: 

  • During open enrollment, ask your human resources team or insurance representative for examples of how Out-of-Network claims are processed under different plans. Ask for examples of therapy Out-of-Network services and how much you would pay under each plan. This can help clarify the potential cost-sharing responsibility.