Out of Network Therapy May be More Affordable Than You Think!

In this post I describe how you can get money back from your insurer -- even for your out-of-network therapist.

I often get contacted by clients who are eager to work with me and who ask whether I am “in-network” (e.g. a member of their insurance carrier’s contracted therapist list).   Like many busy, experienced therapists, I am not in-network with any insurance companies.  

Many current clients actually like that I am not signed up with their carrier, as insurance companies typically request private client information from in-network therapists.  But being out-of-network can leave those seeking more affordable therapy options feeling disappointed.  

Thankfully I have some good news.  Seeing an out-of-network therapist might end up being a lot more affordable than you realize.  

Most PPO plans do reimburse for out-of-network therapy, and for a number of employer plans the reimbursement rate per session is surprisingly high.  I worked in high-tech HR for almost 20 years and have also studied how best to navigate the out-of-network reimbursement system to make therapy more affordable for my clients.

Before diving into the details, though, it is important to note that every insurance plan is different so it’s important to confirm what is available to you with your employer and carrier.  Find out your deductible and what the reimbursement rates are for out-of-network mental health services once that deductible has been met. I often help current and prospective clients collect this information from their carrier and your preferred therapist might be able to help you, too.

Here is how it typically works:

  1. To get reimbursed, a client needs to be on a plan that allows out-of-network treatment.  This usually means a PPO.  HMOs and EPOs, in contrast, generally only allow in-network services.  

  2. PPOs will generally only reimburse for out-of-network mental health services once a client has met the deductible.  If the plan doesn’t have a deductible it may reimburse from the first session -- as is the case for some of my clients -- but more typically a client needs to pay out of pocket for various medical expenses (therapy sessions or other ones) before hitting that deductible and getting reimbursed for out-of-pocket expenses like therapy.  

  3. Once the client hits the deductible -- and if the carrier covers outpatient mental health -- the client will typically be reimbursed for a portion of the session fee.  For instance, if a carrier covers 70/30 of actual cost once the deductible has been met, a client would potentially get 70% of the out-of-pocket payment back from the carrier for subsequent sessions.  For a therapist charging $170 per session, that client would get $119 back, resulting in an effective per-session fee of only $51 for the remainder of the year after the client has reached his or her deductible.

In other words, if a client hits the deductible in March, the per-session cost for the rest of the year would effectively be at a much lower rate.  Like most therapists I ask my clients to pay for the full session cost at the time of treatment, so this payment would generally be in the form of a reimbursement check to the client from the carrier.  I’ve seen a number of clients (particularly on good plans from tech, pharma, financial services and some other progressive employers) repeatedly get four-figure checks from their carriers using the steps above.  In some cases carriers will not reimburse based upon the actual cost of therapy but upon a regionally defined lower rate (e.g. $75), in which case the reimbursement would not be as generous, but clients do typically get some money back once that deductible is met, reducing their effective cost.  The clients who benefit the most from this process are the ones with good PPO plans and who come into therapy pretty regularly (or are otherwise hitting their deductible earlier in the year).

I work hard to help get my clients reimbursed and I encourage you to find out if your current or prospective therapist will help you with this.  In addition to calling carriers to confirm coverage, I proactively submit claim forms directly to my PPO clients’ carriers every quarter, specifying that the client should receive any reimbursement directly.  Submitting claim forms is not a complicated process for the therapists who take this extra step, but it does require knowing how to navigate the system.

The bottom line…

Out-of-network therapy can be more affordable than you might think.  When choosing an out-of-network therapist, ask how he or she will help you get any available reimbursement.  If they only offer to give you a receipt or “superbill” you might want to consider whether you are then likely to try to navigate the complicated process to submit that paperwork to your insurance carrier.  Many clients don’t end up taking that step and leave thousands of dollars on the table in reimbursements.  If your therapist agrees to submit sessions for you I recommend asking how he or she does it and what the results have been for past clients.  As I note above, all plans are different and it helps to confirm coverage details, but many clients can get reimbursement and it helps to have a therapist who can help navigate the process with you.