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Do you have out of network benefits but aren’t sure what it means or how to use them?
Your out of network benefits make it possible to afford therapy and see the provider you want to work with.
In this blog, we’ll cover the basics of using your out of network benefits. You’ll learn how out of network is defined by insurance companies, and see a step-by-step process for using your benefits.
Ready for affordable therapy? Read on.
First up, what does out of network mean? Here’s an easy way to understand it:
Insurance companies have certain professionals that they work with. These professionals are “in network” with the insurance companies. Working with one of them is straightforward → you access their services, your insurance covers their part.
But what if you can’t find an in-network therapist? Or what if your job changes and your therapist doesn’t accept your new insurance? Lastly, what if you simply like working with a professional who doesn’t take insurance at all?
In these cases, your insurance may offer “out of network” benefits.
This means they’ll help you afford therapists that aren’t partnered with your insurance. To say it another way, you work with the therapist you want and part of it is covered by insurance, even though this therapist doesn't have a contract with your insurance company.
Jonathan had insurance through his restaurant job. After much reading online, Jonathan decided he wanted to work with an EMDR therapist for some painful memories he was experiencing.
The therapist that Jonathan found didn’t accept his insurance from the restaurant. Yet, Jonathan still wanted to work with him. Was Jonathan forced to pay 100% of this therapist's fee out of his own pocket?
No. Luckily for Jonathan, his insurance had out-of-network benefits. After paying up to his deductible, Jonathan was reimbursed at what amounted to roughly 70% of his cost of therapy.
While this didn’t completely ease the burden, it helped Jonathan get the therapy he wanted without breaking the bank to do it. The difference added up to hundreds of dollars per month in savings.
There are a few differences between in-network and out-of-network that you should know about. Here are a few:
Weigh these factors and do what makes sense for you. Remember that financial stress impacts your mental health, and only seek therapy that you can afford.
Okay, now you’re aware of what OON insurance is and what makes it different from in-network. If you want to use out-of-network benefits for therapy, you’ll need to know how to get reimbursed.
Insurance reimbursement for therapy can be intimidating. Just saying the phrase “insurance reimbursement for therapy” feels like a lot. But fear not: Thrizer is here to make it simple.
Here’s a simple timeline example:
Step 1: You decide to work with a therapist who isn’t in-network with your insurance company.
Step 2: You verify that your insurance offers out-of-network benefits and will reimburse you. Do this before you access therapy to prevent any surprises.
Step 3: You get therapy from a professional that you vibe with.
Step 4: This therapist gives you a superbill which you submit to your insurance. Alternatively, your therapist can handle the superbill for you and seek reimbursement.
Step 5: Assuming there are no hiccups or hurdles, your insurance company reimburses you. This is usually by paper check and weeks later, but it’s better than nothing.
Getting reimbursed is a simple enough process, though there can be challenges getting the insurance company to pay. More on that below.
A quick note about reimbursement rates.
Before choosing an out-of-network therapist, it's crucial to contact your insurance company to understand their reimbursement rates and requirements. It’s much better to be informed before you start therapy. Financial strain is best prevented this way.
Keep in mind that out-of-network therapy often comes with higher out-of-pocket costs.
A little proactivity up front can help you prioritize your mental health while not causing unnecessary financial strain. Call your insurance company to get the info you need.
And if calling up your insurance company to understand your benefits feels overwhelming, you can always use Thrizer to get an instant breakdown of your out-of-network benefits after linking your health plan.
Sometimes you’ll hear about a “non-participating provider.” Is this the same thing as an out-of-network provider? Let’s explore the major difference.
The main difference between non-participating and out-of-network providers lies in the existence of a formal agreement with the insurance plan.
Non-participating providers may have some billing arrangements and potential reimbursement, whereas out-of-network providers have no direct affiliation with the insurer, resulting in more limited reimbursement and potentially higher costs for the patient.
As always, seek to understand your insurance coverage and the associated costs. Especially when seeking care from these types of providers.
This task can seem very daunting. That’s why we’ve broken it down step-by-step for you.
Follow this process to maximize your chances of getting your therapy sessions covered by OON insurance benefits:
1. Review Your Insurance Policy: Carefully read your insurance policy or contact your insurance company to understand your OON mental health coverage. Pay attention to reimbursement rates, deductibles, co-insurance, and any annual or lifetime maximums.
If you have any questions or confusions, you can use a company like Thrizer to make it crystal clear for you.
2. Choose an OON Therapist: Find a qualified therapist who meets your needs and who you like. Check that they are willing to work with OON insurance and inquire about their billing practices.
3. Confirm The Therapist's Credentials: Ensure your therapist has the necessary licenses and credentials. Insurance companies may require providers to meet specific qualifications for reimbursement.
4. Ask About Fees: Discuss fees with your therapist and ask for an itemized bill that includes CPT (Current Procedural Terminology) codes. This documentation will be necessary for your insurance claim.
5. Pay Upfront: Expect to pay the full session fee upfront, as OON therapists usually do not bill your insurance directly.
6. Get a Receipt: Request a detailed receipt that includes the therapist's name, credentials, contact information, session date, duration, type of service, diagnosis code (if applicable), and the amount paid.
7. Submit Your Claim: Fill out your insurance company's claim form, which you can often find on their website or request by phone. Attach the itemized receipt and any other required documentation. We suggest triple-checking the information you input, as mistakes can lead to denied claims and time wasted.
8. Follow Timelines: Adhere to your insurer's claim submission deadlines. Late submissions may result in denied claims.
9. Be Persistent: Be prepared for the possibility of initial denials or partial reimbursements. If this happens, consider appealing the decision and provide any additional documentation or information requested by your insurer.
10. Keep Records: Maintain organized records of all communications with your therapist and insurance company, including receipts, claim submissions, and correspondence. These may come in handy later.
11. Understand Your Costs: Be aware of your financial responsibilities, including any deductibles, co-insurance, or uncovered expenses. Budget for these in advance.
12. Appeal if Necessary: If your insurer denies a claim, don't hesitate to appeal. Insurance companies sometimes make errors, and a well-documented appeal can lead to a better outcome.
Overall, the process can be more involved than in-network therapy. It's essential to stay informed, be proactive, and communicate openly with both your therapist and your insurance company to maximize coverage for your therapy sessions.
Now you know how to get insurance to cover out of network expenses. Are there any exceptions you should know about?
An out of network exception requires exceptional circumstances.
This type of exception is when your insurance agrees to cover charges from a provider who is not in their network. Usually this is because highly specialized care is required, or there are other compelling reasons to provide coverage.
Beware, out of network exceptions are given on a case-by-case basis. It’s up to your insurance and their methods to decide what will be covered.
Common factors affecting out of network exceptions:
If your initial request is denied, you may appeal this with your insurance directly. When seeking an exception, fight to get approval if you believe it will help your situation.
It's crucial to understand your insurance plan's specific requirements for out-of-network authorization, as failing to obtain proper authorization could result in reduced or denied coverage for the services you receive from out-of-network providers. Being proactive and well-informed about this process can help you navigate healthcare costs effectively when seeking care from out-of-network providers.
We’ve just walked through a maze of understanding out of network insurance. Hopefully you’ve learned what out of network insurance is, gained confidence in asking for it, and are ready to talk with your insurance to verify benefits.
Once you gain access to these benefits, the next challenge becomes successfully getting reimbursed for your therapy sessions.
If you’d like Thrizer to handle the reimbursement and claims appealing processes for you, contact us. We make using OON benefits so easy that you forget that insurance exists.
We’re also working on a database of OON therapists who partner with Thrizer to make their services easy and affordable.
In any case, make sure you get the therapy you need at a price that’s affordable and sustainable.
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This blog post is provided for informational purposes only and is not intended as legal, business, medical, or insurance advice. Laws relating to health insurance and coverage are complex, and their application can vary widely depending on individual circumstances and state laws. Similarly, decisions regarding mental health care should be made with the guidance of qualified health care providers. We strongly recommend consulting with a qualified attorney or legal advisor, insurance representative, and/or medical professional to discuss your specific situation and how the laws apply to you or your situation.
