Print Posted on 04/30/2017 in Insurance

Thinking of Seeing Out-of-Network Therapist? Five Catches to Look Out For

Thinking of Seeing Out-of-Network Therapist? Five Catches to Look Out For

There is an important untold story about using out-of-network benefits to pay for therapy. If you are considering using an out-of-network therapist, you need to know what to expect regarding payment and insurance reimbursement. We’ve collected three known catches and two hidden catches to using out-of-network providers. They go from bad to worse, so read on!

Known Catch 1


Compared to in-network providers, you will pay a higher co-pay and you will probably have a higher deductible. This catch is well known and fairly obvious; however, it isn’t the only one.

Known Catch 2


Most out-of-network providers won't just collect your co-payment at time of service. Instead, you will have to pay for the complete cost of each session. They will then give you a monthly "superbill" which you use to file a claim form to send to your insurance. The reimbursement process takes two to six weeks before you will be paid by your insurance company. This adds unneeded complexity and means that you may be paying in full for your out-of-network sessions for six to seven weeks before you receive a cent from your insurance. For a therapist that charges $150 per session, that means being out nearly $1,000.

Known Catch 3


If your insurance company declines your reimbursement, you are responsible for the cost. Since the provider has no relationship with the insurance company, they are far less likely to know how or be willing to jump through insurance company hoops if there are complications. It’s far more likely that you’ll be left to navigate the insurance company claims process and still potentially be left holding the bill.


Hidden Catch 1


The most important hidden catch of using an out-of-network provider is that your insurance company does not really pay 50% of your bill. In reality, they pay 50% of what they consider "reasonable and customary" for a professional of similar qualifications in that area. So if your therapist is charging $150 per hour, but your insurance company considers a "reasonable and customary" fee to be $66, they will only pay $33. This leaves you covering the remaining balance of $117 when you only expected to pay $75. It is important to know that what one company considers "reasonable and customary" is often very different from the reality of what therapists typically charge. It is not unusual to see therapists charging $150 per session in a metropolitan area, but insurance companies claiming that $70 is "reasonable and customary".

Hidden Catch 2


There is no way of knowing what "reasonable and customary" charges are ahead of time. Insurance companies simply do not disclose that. The only way to find out is to submit your bill and wait two to six weeks to see how much they reimburse. By the time you find out what you are being reimbursed, you will have seen your therapist half a dozen times (or more) and have developed a significant relationship with your therapist. It can be emotionally and therapeutically damaging to switch to an in-network provider simply due to cost at this stage in therapy.

What Can You Do About It


The easiest answer is to choose an in-network therapist. But if you really have your mind set on an out-of-network provider, make sure to carefully research the known catches ahead of time and make your decision based upon facts. If it still seems worth seeing a particular provider given these potential costs, especially knowing that there isn’t much to be done about the hidden catches, have a conversation with your provider. Often, you can discuss your concerns with your therapist ahead of time. Many will understand the lack of certainty around reimbursement and will work with you to help. Try saying something like, "I want to see you, but I am worried about how much my insurance will cover. If it turns out that they cover only a small amount, will you be able to lower your cost to make therapy affordable for me?"


So Is It Worth It?

The decision to use an in-network versus out-of-network provider depends on how important it is for you to have absolute choice over who you see. If you choose an in-network provider, your choice of therapist is going to be limited. However, it is likely to be substantially cheaper and less complicated. If you choose an out-of-network provider, you have the benefit of choice, but you take a big gamble financially and emotionally. Go in
with your eyes open and remember to consider all of the factors here before proceeding.


 

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