Insurance and Services: Understanding Out-of-Network Coverage
Navigating the insurance world can be complicated. You’ve found a provider who feels like a good fit, but they don’t accept your insurance. So what do you do next?
Let’s break down some key terms.
In-network (INN) provider: a provider who is paneled with your insurance company and bills the insurance company directly. When you work with an in-network provider, you pay a co-pay to the therapist, and they take care of the rest.
Out-of-network (OON) provider: a provider who is not paneled with your insurance company and cannot submit claims on your behalf. When working with an OON provider, you will pay the provider directly, and then submit the claim yourself to your insurance company for any potential reimbursement. If eligible, the insurance company will send a check for reimbursement directly to you.
Superbill: A superbill is a summary of the services provided which is given to you by the provider. One you have this, you submit it directly to the insurance company. Insurance companies will not accept standard invoices as proof of service. The superbill contains all the providers necessary information (license number, NPI, Tax ID) and the information regarding your service (session type, length of session, location of session, and diagnosis). The decision to reimburse is made by the insurance company, and the provider does not have say in this.
Do I have reimbursement potential?
Check your insurance card
Some insurance cards have this information printed right on the front of the card. If so, it will state both the in-network and the out-of-network deductible costs. If your card does not have any OON information printed on it, you will have to check your client portal with the insurance company, or call them directly.
Call your insurance company
To check coverage over the phone, call the customer service number on the back of your insurance card. You will listen to the prompts and select the option to review benefits and eligibility. Once connected to a customer service representative, you will ask them the following questions:
Do I have out-of-network coverage for outpatient mental health services with a licensed and board certified psychiatric-mental health nurse practitioner for the following CPT codes?
99205
99214
99213
90833
Is there an out-of-network deductible?
What percentage will I be reimbursed?
Is there a pre-authorization required?
How do I go about submitting a claim?
It is helpful to record the name of the representative and ask for a reference number for the phone call.
A couple more notes
There are some non-negotiables when using insurance
When using your insurance, whether in-network or out-of-network, your provider is required to provide the company with a mental health diagnosis. This diagnosis becomes a part of your permanent medical record with the company. Additionally, when using insurance to cover sessions, they can request progress notes, treatment plans, or other documentation about your progress. They can deny payment if they do not feel services are medically necessary. This is something outside of the providers control, no matter how much supportive evidence is provided.
Not all insurance plans are made equal
Being transparent pricing, so you can make the best decision for your care, is important. Even if you have an insurance plan in network with your provider, depending on your plan, your out-of-pocket costs (such as deductibles, copays, or coinsurance) may be higher than self-pay rates.
If you have a high-deductible health plan or have not yet met your deductible, paying my self-pay rate may be a more affordable option than using your insurance. I am happy to review your estimated costs and discuss both options with you before your visit; this is often referred to as a “good faith estimate”.