Using your out-of-network benefits

I’m fully out of network, so you pay me directly and your plan may pay some of it back to you. This page covers how that works. The fees themselves are on the fees page.

What “out of network” means

I haven’t signed a contract with any insurer, so you pay my full fee rather than a copay, I don’t submit claims or talk to your insurer, and whatever your plan pays back, it pays to you. Many plans, especially PPOs, still cover part of it.

It keeps decisions about your therapy between you and me. An insurer paying directly gets a say in how many sessions you have and can ask for details of the work to justify them. Here there’s no session limit and no utilization reviewer deciding whether your treatment is necessary. It also keeps the practice simple: one clinician, no billing department, and the same fees for everyone.

Superbills

A superbill is an itemized receipt in the format an insurer needs for an out-of-network claim; you’ve already paid, and it lets you ask your insurer for some of it back. Mine lists each session date, the service, the fee you paid, my license number and National Provider Identifier (NPI), and the procedure and diagnosis codes insurers require. Sessions are by video, so the place of service on it is telehealth.

At the start of each month I send you one through the client portal, covering the previous month’s sessions. You submit it through your insurer’s member website or app, or by mail with their claim form. You don’t have to submit monthly: most insurers accept claims for a while after the session, often up to a year, but check your plan’s deadline.

How much will my insurance pay back?

It depends on four things in your plan:

• Out-of-network deductible: what you pay before the plan reimburses anything. It’s often separate from your in-network deductible, and larger. Superbills count toward it, so submit them anyway.
• Allowed amount: what the insurer considers a reasonable fee, sometimes called the “usual and customary rate.” It’s often less than $250, and reimbursement is calculated from it, not from what you paid.
• Coinsurance: after the deductible, the share of the allowed amount the plan pays, often 50 to 80 percent.
• Out-of-pocket maximum: many plans cap what you pay each year for out-of-network care, after which reimbursement rises.

For example, with made-up numbers: your deductible is met, your plan allows $150 for a session, and it pays 70 percent. You’d get $105 back of the $250 you paid.

Questions to ask your insurance company

Call the member services number on your card and ask:

1. Does my plan have out-of-network benefits for outpatient mental health care?
2. What is my out-of-network deductible, and how much of it have I met this year?
3. What percentage do you reimburse after the deductible?
4. What is the allowed amount for procedure code 90834, a 45-minute individual psychotherapy session? For couples, ask about 90847.
5. Do you cover telehealth sessions out of network?
6. Do I need pre-authorization?
7. How do I submit a superbill, and what’s the deadline?

Note the name of the person you spoke to and the date, in case a claim comes back differently from what you were told.

HMOs, EPOs, and Medicare

HMO and EPO plans often cover no out-of-network care, so a superbill may get you nothing back. I’ve formally opted out of Medicare, so Medicare won’t reimburse sessions with me, and a Medicare beneficiary and I would first sign a short private contract saying so. Better to know that before we start.