Out-of-Network Benefits Cheat Sheet

New to out-of-network benefits? This resource is just the cheat sheet you need!

We'll cover the basics of what OON benefits are and why they can be a powerful tool in providing financial relief to clients and in turn, help you convert and retain private pay clients with more ease.
‍

What are out-of-network benefits?

Out-of-network benefits is coverage provided by a client's insurance plan for healthcare services, in this case therapy, received from providers who are not part of the plan's network.

In simpler terms - even if you don't accept insurance directly, a client may have out-of-network benefits in their insurance plan that still allows them to receive some money back on therapy.

Out-of-network benefits for therapy reimburse on average 70% of the session cost, allowing the client to recoup a large portion of the therapist’s full fee, all while the therapist earns their full rate.

‍

Why is this good news for therapists?

Out-of-network benefits can give therapists the confidence to charge their full rate without the guilt of needing to accept insurance to remain accessible. They allow you to tap into a broader set of clients beyond the insurances you may be paneled with while still ensuring those clients have a way to save on their sessions.

Alternatively, they also give you the confidence to go fully private pay and not have to deal with insurance altogether.

Not only does that mean no longer needing to accept low reimbursement rates set by insurance, it also means no more audits, clawbacks, notes, hours on admin work, etc. since insurances do not mandate them for out-of-network claims. On very rare occasions do they ask you for more documentation.

Ultimately, OON benefits provide therapists the freedom to charge what they deserve, give back time normally spent on insurance hassles and admin tasks, and set a much more manageable caseload.

‍

Why is this good news for clients?

Out-of-network benefits provides clients the freedom to see the therapist they want to see without cost being a large deterrent.

Cost is often a big barrier for therapy, allowing clients to only access therapists who accept their insurance. However, it may be difficult to find an in-network therapist quickly, especially one that specializes in the specific needs of the client.

Furthermore, clients may find an out-of-network therapist who is a much better fit for their goals and be discouraged to commit to therapy with them because of the cost. By cutting their out-of-pocket cost to less than half, clients finally have the option to access a larger pool of therapists.

Ultimately, clients can find a therapist who is a good fit and afford to see them as frequently as they wish.

‍

Which plans typically have out-of-network benefits?

A majority of PPO plans have OON benefits. Many non-PPO plans also have OON benefits. The policy varies by plan, so we always recommend checking benefits for that particular plan to be sure. Clients can call their insurance company to verify their benefits. Thrizer can help with these benefit checks free of charge.

Which plans do not have OON benefits? HMO plans as well as Medicare and Medicaid do not have OON benefits.

‍

How do clients access their out-of-network benefits?

The primary difference between in-network and out-of-network therapy is that it is on the client to submit out-of-network claims to insurance themselves.

Clients will generally pay the provider's full fee upfront, submit an insurance claim, and wait for reimbursement.

A therapist needs to provide the client with a superbill, a document that summarizes the sessions they’ve had along with other information such as a diagnosis, CPT code, and provider NPI.

The client can submit this superbill to their insurance and once approved, receive a reimbursement check for a portion of the cost. Reimbursement waiting periods vary by plan but can take on average 4-6 weeks.

‍

How are reimbursement rates determined?

Reimbursement rates vary by individual plans. Client's can only know their exact reimbursement amount after they hear back on their first claim.

Here are the important components that determine the reimbursement amount:

Allowed amount: The allowed rate is the maximum amount that insurance will accept and reimburse for therapy.

Deductible: The amount a client must pay out-of-pocket before out-of-network reimbursements begin.

Co-insurance: The percentage of the allowed amount the client is responsible for after they've met your deductible.

Estimated Reimbursement: The estimated payment the client will receive from their insurance for a therapy appointment.

‍

Let's run through an example!

A client's out of pocket cost for therapy sessions is determined by the deductible, allowed amount, and co-insurance.

Let's assume: The clinician's rate is $200, deductible is $1500, allowed amount is $150, and co-insurance is 20%

Pre-deductible: The client would pay the full $200 fee for the first 10 sessions before receiving reimbursements for each session. Only the $150 allowed amount gets applied towards the deductible for each session (hence, $1500 / $150 = 10 sessions).

Once the deductible is met: Since the client's co-insurance is 20%, insurance will reimburse the remaining 80% of the $150 allowed amount. Therefore, the reimbursement amount is $120/session.

The client's out-of-pocket cost is the difference between the provider's fee and the reimbursement amount. So, if the provider's fee is $200 and insurance reimbursement is $120, the client's out-of-pocket cost is $80.

This means, you earn $200 while the client only pays $80 per session!

‍

How can clients skip the reimbursement wait?

While out-of-network benefits are incredibly helpful, reimbursements weeks later may not help individuals access therapy today. When they submit their own superbills, they would still be responsible for paying the provider's full fee at the time of the session, meaning they could be out hundreds of dollars before receiving reimbursements several weeks later.

This is where Thrizer can help. After clients meet their deductible, Thrizer lets clients just pay their out-of-pocket cost i.e. their co-insurance for sessions.

Thrizer covers the rest of the provider's fee and waits for reimbursement on the client's behalf. This allows clients to afford therapy upfront while ensuring therapists receive their full rate upfront as well. Thrizer takes on the burden of insurance entirely.

You can get started with this onboarding guide to learn more and get started in minutes. Thrizer will instantly verify client benefits and start saving them upfront on therapy.
‍