Everything You (N)Ever Wanted to Know about Out of Network Reimbursement from a Massachusetts Anxiety Counselor: Don’t leave money on the table
If you are paying out of pocket for therapy, are you getting any reimbursement from your health insurance? If you’re considering out of network therapy, did you know your insurance might pay for part of it?
If you have out of network benefits, I want you to take advantage of them!
I’m Bronwyn, online anxiety therapist for women and HSPs in Boston and throughout Massachusetts, Wisconsin and Washington, DC. I know, insurance is the thing that gives you anxiety! Yes, it is a beast to deal with. But getting more information about how things work and what your benefits give you can help reduce your anxiety. Today I’ll be walking through the steps and information you’ll need to use your out of network benefits for mental health therapy.
In Network vs. Out of Network: what’s the difference?
You’ve likely heard the terms “in network” and “out of network.” Commonly this is referred to as whether a therapist “takes” your insurance. The answer might leave you with more options than you would have thought.
I often get asked if I “take” a particular insurance. If a therapist takes your insurance, it means that they are “in network” with that insurance company. This means that the insurance company pays the therapist directly for most of the session cost. You make up the difference, after hitting your deductible, in the form of a copay. If you are using in network benefits, your pre-therapy financial planning task will be to know your deductible and your copay.
However, you may want to broaden your search for a therapist by looking out of network. (Or you may already be working with an out of network therapist and don’t know what your insurance benefits are.) If you want to look outside your insurance network for mental health therapy, it doesn’t necessarily mean you’ll be responsible for the entire cost. Even if a therapist doesn’t take your insurance, your insurance might pay for part of your therapy. Depending on your insurance plan, you could make claims for partial reimbursement.
I imagine that anything to do with checking your insurance benefits probably gives you hives, and with good reason! In the following steps, I’ve tried to sort out the process so it feels more manageable. Here’s a breakdown of what you’ll need to do.
Check your insurance plan for out of network mental health benefits
This is usually listed in the “Summary of Benefits,” which is in the member packet you get or online. What it should tell you:
Whether you have “outpatient mental health” benefits out of network
“Outpatient” refers to things like therapy sessions. This is different from “inpatient” which means you spend time in the hospital during a mental health emergency.
Your out of network deductible
Your deductible is the amount that you will need to pay before your insurance company will pay for anything. This renews every calendar year. The out of network deductible is typically higher than the in network deductible.
The out of network Coinsurance amount
This is the percentage of the therapist fee that you will be responsible for paying.
I would like to tell you it is as simple as multiplying the session fee by your coinsurance amount to find out what you will ultimately be responsible for paying. In fact, there’s one more step.
Insurance companies also have a tricky thing called the “allowable amount.” It’s the amount of the session fee that they say is the maximum they’ll consider as the fee. In other words, it puts a cap on the session fee. For individual therapy sessions, I've seen the allowable amount range from $60-$200. For example, if your therapist charges $200/session and the allowable amount is $100, it means that your insurance company will pay 60% of $100 (not 60% of $200). This is not a published number, but when you, most insurance companies will provide it to you. More about the allowable amount below.
2. Verify your Out of Network coverage details
Even if you have some financial flexibility and don’t need to know what the allowable amount is, you'll want to call your insurance to verify your out of network benefits. For those of you who hate phone calls, many insurance companies offer online chat as an alternative. The agent needs to verify what your specific benefits are.
Whether it’s phone or online chat, here’s what you should ask:
What’s my out of network deductible for outpatient mental health?
What’s my out of network coinsurance for outpatient mental health?
Are there any limits on the number of out of network outpatient mental health sessions per year?
Are there limitations on telehealth mental health sessions?
Do I need a referral to see an out of network provider?
How do I submit a claim for out of network reimbursement?
How much of my deductible has been reached this year?
What is the allowable amount for outpatient individual therapy sessions?
For this one, you will want to get the allowable amount for CPT 90834, 45 min and CPT 90837, 60 min (we’ll go over what the CPT is below). Your therapist might provide 45-50 minute sessions or 60 minute sessions. (If you want to know what the one time intake session allowable amount is, you can also ask for CPT 90791. It’s typically higher than individual therapy sessions.)
In order for the insurance company to provide you the allowable amount, they may ask for more details about the specific therapist (address, NPI, and license) as the allowable amount varies by location and experience. If so, you can ask any therapists that you are interested in working with for this information. If you’re currently working with a therapist already, you can simply file a claim with a superbill, and when you get reimbursed, you’ll see the amount.
Once you have made the call, woohoo! Congratulate yourself! No one likes calling insurance companies. On top of that, money is a hot topic that causes most people anxiety. You may want to take a minute to employ some of your favorite anxiety coping skills before moving on to the task of plugging in your numbers. You got this!
3. Estimate your final cost
Now for the fun part! You can use all the numbers you got to see what your scenarios will look like with your current or potential therapists. Here’s an example:
Let’s say your numbers are as follows:
Out of Network Deductible = $5000
Coinsurance = 40%
Session fee = $200/session
Allowable amount = $100/session
This means that for the first 25 sessions, you are responsible for the entire session fee. At that point you will have reached your deductible (25 sessions x $200). If you are paying for other medical expenses toward your out of network deductible, it would be less than 25 sessions of course. Whenever you have reached your deductible, from all medical expenses, your coinsurance kicks in. At this point, your insurance company will reimburse you, after you file a claim, for 60% of the allowable amount: in this example, 60% x $100 = $60. That lowers your net cost per session by $60, and you will end up paying $140/session after reimbursement.
Keep in mind that the process of filing a claim and getting reimbursed can take months. So you’ll need to be able to pay the entire amount upfront and then wait for the insurance reimbursement.
4. File an insurance claim
Many insurance companies are making good changes so that it’s easier to submit claims. Keep in mind that insurances make more money if you don’t file any claims. This means they are invested in making the process as difficult as possible. It’s ok if you know you won’t have the energy for doing this! However, it can also be helpful to look at claims filing as a way that you are exercising your own agency and control. It’s also pretty great to get a reimbursement check!
Sometimes the process is easily identifiable online, and sometimes a phone call or online chat is needed. Often, once you make once claim, the subsequent claims are easier. Sometimes you will need to input information manually, and sometimes you can just scan a document called the superbill (see below for more info). All the information you need for the claim should be included on the superbill.
What is a Superbill?
If your insurance coverage will reimburse for your therapy sessions, you’ll need something called a Superbill. This is insurance language for a document that includes everything they need in order to process the claim. It’s not your responsibility to create any superbills. Your therapist will do that. It’s become pretty standard practice to offer these to clients. In fact, most electronic health records will create them automatically. All you need to do with the superbill is download it and send it to your insurance company as part of the claim you make for reimbursement.
Sometimes your therapist may file the claim for you. Most often however, you will be responsible for filing the claims yourself.
In filing the claim, you may need to input specific information from the superbill. In addition to names, addresses, and your date of birth, here’s what’s required on the superbill:
Your therapist’s National Provider Identifier (NPI)
This is a number that uniquely identifies a provider, mainly for use in billing insurance. All medical providers who bill insurance will have one. If your therapist doesn’t bill insurance but you make a claim, the insurance company will need this number.
Your therapist’s license number
Therapists are licensed by state. Your therapist needs to be licensed in the state where you live. Your superbill might include the license numbers for all the states that your therapist is licensed in.
Diagnosis code
Most insurance companies won’t pay for therapy unless you have a diagnosis. Sometimes diagnosis is listed by the abbreviation “dx” on the superbill. The superbill will list the diagnosis code and name. For example, you might see F43.22 Adjustment Disorder with Anxiety.
Service Code or CPT code
Similar to your medical doctor, there are multiple kinds of treatments that your therapist could be providing. Across all medical professions, these services are standardized into codes called Current Procedural Terminology. The codes specify what kind of service was provided and how long it lasted. For example, CPT code 90834 is the code for Individual Psychotherapy, 45 minutes. You don’t need to worry about what the codes mean. You may be asked to fill out the specific code as part of the claim however. If you do, the form might call it a “Procedure Code” or “ICD10 Code.”
Place of Service (POS)
Insurance companies need to know where the service was provided. Healthcare services can be provided in a variety of settings (think emergency room or a clinic office), and insurance needs to know where the therapy took place. If you’re going to your therapist’s office, this number will likely be 11, and if you’re doing telehealth therapy, this number will likely be 02. Most insurances continue to cover telehealth therapy, but it varies by state.
If you made it to the end, congratulations!
Well done in prioritizing your mental health and ways to pay for support.
Once you’ve gotten your insurance benefits, you can start filtering through possible therapists more easily. Make sure you give yourself lots of kudos along the way. Finding a therapist is not an easy task, but has the potential to pay dividends on your efforts!
About the Author
I’m a counselor for anxiety who loves supporting women and HSPs to feel more in control.
Based in Madison, WI, I provide virtual therapy throughout Boston and Massachusetts, online therapy in Washington, DC and telehealth therapy in Wisconsin. In addition to anxiety therapy, I also offer depression counseling and therapy for Highly Sensitive People.