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New to out-of-network benefits? This resource is just the crash course you need!
We'll cover the basics of what they are and why they can be both a client and a therapist's best friend in helping make therapy more affordable.
If you've already received a breakdown of out-of-network benefits, you can also visit this resource on how to better understand the 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 a client's therapist doesn'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.
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 therapists to tap into a broader set of clients beyond the insurances they may be paneled with while still ensuring those clients have a way to save on their sessions.
Alternatively, they also give therapists 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. Ultimately, it provides 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.
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 may specialize 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.
The primary difference vs. in-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.
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 visit www.thrizer.com to learn more and get started in minutes. Thrizer will instantly verify client benefits and start saving them upfront on therapy.
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.
