What is an Out of Network (OON) Provider?

While many large practices and doctors offices are in network with a variety of insurance companies, many independent therapists are out of network (OON) providers

An out of network provider is a provider does not have a contract with the insurance company.

A therapist can be in-network with some providers, and out of network with others. They can also be private pay only.

If a therapist is private pay, this means that they do not directly work with the insurance companies. They will tell you how much a therapy session costs and you pay the therapist at each session. The therapist may provide a superbill for your sessions which you can submit to your health insurance company for reimbursement if your plan offers out of network benefits. Once submitted, the insurance company will send you the reimbursement for your expenses directly.

Different insurance companies offer different out of network reimbursement rates.

An HMO insurance company does not (generally) allow a client to see an out of network provider.

Why Do Some Therapists Only Accept Private Pay Clients?

Some therapists, particularly those with small practices, only accept private pay clients.

There are a number of reasons for this, including:

  1. There are fewer administrative tasks involved with private pay, resulting in 5 hours or more per week of additional time to see clients or complete other business tasks.
  2. Insurance companies require that you sign a contract with them and abide by the rules of the contract. These rules are not always in the client’s best interest.
  3. We can keep our caseloads lower. This allows us to:
    • Avoid burnout
    • Dedicate more time to additional training and education.
    • Spend more time planning effective sessions.
    • Offer longer sessions when helpful (insurance companies offer a max of 45 or 60 minute sessions).
  4. Some therapists offer a specialty that involves more business expenses and the insurance rates don’t compensate well enough to cover these expenses.
  5. With private pay, therapists get paid immediately, rather than 4-8 weeks after submitting an insurance claim. This allows us to budget to pay for business expenses.
  6. Insurance companies don’t reimburse according to experience in the field or specialty expertise.

Larger group practices are more likely to accept insurance because they often have a person dedicated to the administrative tasks that a small practice owner would otherwise be responsible for (ie. billing and calling insurance companies, making appointments, bookkeeping etc.). They also have enough clients in and out of the practice to balance out the potential issues. For example, even if one insurance company is slow to pay, the other three might be on time that month. This means the company isn’t going to be short money to pay employees or to pay their rent. This is much harder for small practices.

Therapists with more training and experience are often out of network. People in specialty niches often tend to be out of network as well because our certification programs are expensive and running the practice can be more expensive as well. 

Checking Your Out-Of-Network Benefits

As an out-of-network provider, I have partnered with Mentaya to help my clients save money on therapy. Use this tool below to see if you qualify for reimbursement for my services.

The company also offers assistance filing claims. If you qualify to use out of network benefits, Mentaya can handle everything with insurance to make sure you get your money back. They charge a 5% fee per claim. I pay a monthly fee for the benefits checker to be added to my site for your convenience, but you would be responsible for the 5% fee. Submitting the bills yourself is feasible, but I like this option if you’re overwhelmed and need a little assistance. I do not get any kickbacks if clients sign up for Mentaya for claim assistance.

I also a wrote up some information on submitting superbills. Check Out: Learn more about Submitting Superbills