Out-of-network therapy reimbursement is simpler than it looks. You pay the therapist directly. Then you submit a receipt to your insurer, and they reimburse a portion. Because the paperwork sounds tedious, many people assume out-of-network care is unaffordable. Often it is not.
What “Out of Network” Actually Means
An out-of-network therapist is not contracted with your insurance company. Therefore they do not bill your insurer, and the insurer does not set the fee.
You are still likely to have out-of-network benefits. Most plans other than HMOs include coverage for out-of-network outpatient mental health. HMO plans generally do not reimburse for care outside the network at all.
Why Some Therapists Stay Out of Network
Being paneled with an insurer has three consequences. First, it requires assigning a hard diagnosis, sometimes earlier than the clinical picture justifies. Second, that diagnosis and other clinical information go into a third-party record. Third, the insurer decides how often you are authorised to be seen.
Staying out of network keeps the diagnosis honest, the record private, and the frequency of sessions a clinical decision rather than an administrative one.
What to Ask Your Insurer
Call the member services number on the back of your card. Then ask these questions:
- Do I have out-of-network outpatient mental health benefits?
- What is my out-of-network deductible, and how much of it have I met?
- What percentage do you reimburse after the deductible?
- Is there a limit on the number of sessions per year?
- Do you reimburse telehealth at the same rate as in-person sessions?
- How do I submit a superbill, and what is the deadline?
Write down the answers and the reference number for the call. As a result, any later dispute is far easier to resolve.
The Superbill
A superbill is simply an itemised receipt. It lists the dates of service, the service codes, the fee paid, and the provider details. You submit it through your insurer’s portal or by post.
Reimbursement usually arrives within a few weeks. Meanwhile, keep copies of everything you send.
Good Faith Estimates
If you are uninsured, or insured but choosing not to use it, federal law entitles you to a Good Faith Estimate of expected charges before scheduling. You can also request one at any time.
The estimate reflects reasonably expected costs. It cannot account for unforeseen complications. If you are billed at least $400 more than the estimate, you can dispute the bill. More information is available at cms.gov/nosurprises or by calling (800) 368-1019.
How This Practice Handles It
Michael Nee, M.A., LMFT (#89379) is out of network and not paneled with any insurer. Receipts are provided for every session. Cancellations require 36 hours notice, and reminders go out 48 hours in advance.
Full detail is on the FAQ page. To arrange a free 15 to 40 minute consultation, call (310) 927-1755 or use the contact page.