Insurance is MASSIVELY confusing, Many people find it difficult to determine if their insurance covers out of network services. I’m going to talk a bit about this today.
Out of network providers are providers who are qualified to provide the service, but don’t credential directly with the insurance companies. Many small scale providers (vs group practices) make this choice as insurance companies don’t always pay providers in a timely manner and unfortunately, the mortgage or rent can’t be paid ‘whenever.’
This is complicated with the fact that therapy practices have quite a bit of overhead costs. Costs that need to be paid on schedule… not whenever the insurance company provides compensation.
Add this to the fact that insurance companies set the reimbursement fees- providers do not get raises (it’s very rare that the insurance companies raise their rates)… a new therapist will generally get the same fee as a clinician who has been in practice 40 years.
And then there are times when you’re submitting claims or sitting on hold, unpaid, trying to figure out why the insurance companies aren’t paying the amount that they stated they would.
It’s really unsustainable for small practices. Big practices with 10+ clinicians can split the cost of a secretary to manage this piece.
Fortunately, many people have out of network coverage with their insurance. HMOs don’t cover out of network providers, but PPOs usually do.
What does this look like? The client pays the therapist their fee, then submits the receipt (a superbill) to their insurance company. The insurance company then reimburses the client according to the coverage- the client receives a check back. This is tough for the first few sessions, but once reimbursement starts coming consistently, it’s much more sustainable.
Here’s an example…. this is going to be a bad example because I’m making up the plan. I’m waiting until November 1 to pull the latest plan options for 2026 as we are personally shopping for a plan with out of network coverage.
Plan:
Out of Network Deductible: $1000
Coverage After Deductible: 80%
Scenario:
The client will attend 5 therapy sessions (at $200/session) to meet the deductible… each session is submitted to the insurance company, but no reimbursement will be given (unless they met the deductible at another out of network practice).
After meeting the deductible, each session the client will pay the $200 and submit for reimbursement to the insurance company. The insurance company will send them a check for $160/session. This results in a client cost of $40/session once the deductible is met.
This is more sustainable than it would have seemed originally, particularly if you know you’ll want to see different out of network providers in the insurance year (very common when you have a child who needs speech and language, OT, therapy, and psychiatry visits)… although, we can all likely agree that it would be far better if insurance companies weren’t for profit entities making between $5-22 billion dollars each year.
I’ve found that many people DO have out of network coverage… and they don’t know it! I know people who have paid for out of network providers, not realizing that they could be reimbursed! Y’all- GET THAT MONEY BACK!
I use a service called Reimbursify to let clients check their out of network insurance coverage. I pay a flat fee for the app.
To check your out of network coverage through my Reimbursify account, here are the instructions:
- Go to this page: https://happyhoneysuckle.org/faq/
- Find the Reimbursify R in the bottom right and click VERIFY YOUR BENEFITS.
- Input your info.
I’m not sure how quickly it will spit back coverage information- I can’t demo it with my own insurance because we have an HMO and even the in-network coverage is BAD. But it should give you the information either immediately or within 24 hours.
I hope this helps!