Can I Afford Therapy? A Step-by-Step Guide to Using Insurance and Out-of-Network
The Ripple Effect of Healing
As a mental health clinician, I want to reach as many lives as possible. If I can guide one person through a challenging time, I know that person's healing will have a cascade effect on those around them. Their children, spouses, work colleagues, and friends will benefit from their improved mood and emotional stability. The time that the client spends with their family or friends will be more energized and fulfilling; the quality of their work will improve; their physical health and sleep will get a boost. So, knowing this, as I set up my private practice, I had to decide on the best way to serve my clients while also honoring my own needs.
Balancing Self-Care and Client Care
Here's the truth: If I take good care of myself by creating a healthy work-life balance, I can more easily care for my clients. One way I have attempted to achieve this goal is by offering 'fee-for-service' counseling rather than accepting insurance for my counseling and psychotherapy services. Within my practice, clients pay by credit card, HSA, or FSA at the time of their service. Therefore, I am considered an "out-of-network" or "OON" provider. Being OON allows me to quickly and efficiently handle the administrative side of my business, and this, therefore, frees up time for me to read more clinical books, take more interesting classes on topics that are important to my clients, and serve more clients each week. In my opinion, it's a win-win.
Challenges of Working with Insurance Companies
There are many reasons why working with insurance companies is difficult, tedious, and can feel unethical at times. I won't bore you with all the reasons, but suffice it to say, if they can make things difficult, they will. Sometimes they reject payments for no good reason. Other times, they limit how many times you can come to therapy in a calendar year or the length of our sessions. They also determine what diagnoses they are willing to pay for and what type of treatment we should provide, and, of course, all of this must be properly documented.
I have heard horror stories of audits by insurance companies that result in therapists being asked to repay thousands of dollars for incorrect documentation! Personally, this would have a detrimental impact on me, and therefore on you, the client. And of course, none of these hurdles or threatened 'clawbacks' are in the best interest of the clients I treat. And, beyond that, they can severely impact appropriate care. So, I have set up a practice that allows me to inform care using my clinical judgment and best practices, and one that is not fear-based.
The Cost of Therapy and Financial Stress
Nonetheless, I understand that therapy can be expensive, and you might wish to use your insurance to make it more affordable and accessible. I cannot argue with that. Financial distress is one of the main reasons why people seek psychotherapy; without some sense of financial security, stress mounts, depression rises, and anxiety takes over! Of course, people with financial resources and privilege have their share of challenges too, but when we cannot meet our basic needs, we go into survival mode, and that takes a devastating toll on our mental and physical health.
Understanding Your Insurance Benefits
As a therapist with over 10 years of experience, I have come to realize that many of my clients don't know where to start in understanding their insurance policy. This can cause overwhelm, anxiety, and, ultimately, inaction. In other words, my clients often have the best intentions of figuring out how to use their "out-of-network" benefits when they get my Superbill each month, but they fail to submit it for reimbursement. This, in turn, adds to their anxiety by triggering a sense of being a failure or inadequate, or it adds to their distress about not completing a 'simple' task like submitting this claim. So, let me help you remove this barrier to treatment!
A Step-by-Step Guide to Using Out-of-Network Benefits
With this guide, you can determine the cost of therapy – based on your particular insurance policy, out-of-network benefits, and deductibles – and you can therefore make an informed decision about starting with a therapist like me. Furthermore, once you get started, you will need to know how to seek reimbursement from your insurer. I hope this guide makes things easier for you!
Please know that seeking reimbursement is your right. You are paying for this insurance benefit, whether you use it or not, and when you do not use it, the insurance companies make more profit. In real numbers, seeking your reimbursement regularly will make a difference to your monthly expenses.
Imagine you pay $400 per month for therapy and come regularly for 9 months. That's $3,600 in out-of-pocket costs. Then imagine that your insurance company reimbursed you 50% of what you paid. In this example, you would receive $1,800 back. That might equate to several car payments, a month's supply of groceries, or several weeks of summer camp. It's worth it to seek your reimbursement! This is a great way to ease your financial distress.
Step 1: Contact Your Insurance Provider
Warning: this step might be the hardest part! Depression makes it difficult to gain the motivation for this step and anxiety causes a lot of worry and overthinking in anticipation of this phone call. Anxiety will also make you avoid this task. I am here to encourage you to do it anyway, even when you are scared or lack the desire to make the call!
Locate your insurance card, and on the back, you will find the customer service number. Call this number and ask to speak to someone about your benefits. Have pen and paper nearby and be prepared to go through a lot of automated steps before getting to a real person! Plan accordingly – at least 15 minutes. Know who holds the policy, the name of their company, and their birthdate. Be prepared to answer security questions and passwords associated with this account.
Alternatively, log on to your insurance company's patient portal and see if you can find the information about submitting a claim electronically.
Step 2: Clarify Your Out-of-Network Benefits
Ask the associate to explain your "out-of-network benefits" to you. Tell them you are seeking psychotherapy or counseling, and you will be paying upfront, at the time of service, and you will then be seeking reimbursement from them. If they ask you for specific CPT codes (the billing codes that providers use to specify a service), the most common codes that my practice uses are:
90791 (Psychiatric Diagnostic Intake)
90837 (50 min Psychotherapy)
90834 (40 min Psychotherapy)
90853 (Group Therapy)
You can also tell them that we use the "Modifier" of 95 to specify telehealth.
Questions to Ask Your Insurance Provider
Do I have a deductible to meet before I can get reimbursed? If so, how much?
How much can I expect to receive in reimbursement? Bear in mind that most companies offer a percentage back, not the whole payment. My clients have reported receiving a range of 30 – 80% back of their payments.
Are there any limitations on how I can use this benefit?
What is the process for seeking reimbursement? Or, where/how do I submit my Superbill?
When should I expect to receive my reimbursement? Does this take days, weeks, or months?
What do I do if a claim gets rejected?
What happens if you send the reimbursement to my therapist, instead of me? (This happens occasionally)
Step 3: Scheduling and Payment Process
Assuming you have all your answers and are ready to proceed with a private-pay therapist, you can schedule your first appointment. In my practice, all new client paperwork is automatically sent via email when you register. Within that paperwork, I will explain my payment process, and I accept credit cards, HSAs, and FSA cards. At the time of writing, I use a HIPAA-compliant 3rd party vendor called Ivy Pay. I send you a text message via Ivy Pay, and you follow the link to enter your credit card info. This card is automatically charged with each appointment. I prefer this system as I never personally hold your credit card info; I let the experts do that!
Step 4: Obtaining and Submitting Your Superbill
After your therapy session, I email you an invoice, and each month (or more frequently, if you prefer), I email you a Superbill. The Superbill is the document that your insurance company will require you to submit for reimbursement.
With your electronic copy of your Superbill, you are now ready to submit your claim via whatever process your insurer uses. Refer to the information you collected in Steps 1 & 2 to complete this accurately. Each insurance panel is different, so I cannot guide you here – you will have to refer to the notes you previously made, or, of course, call your insurance company again. Below, I have listed some links to useful information about this process with Maryland's most popular private insurance companies:
Aetna
BlueCross Blue Shield
Cigna
United Health Care
Step 5: Tracking Your Submissions
Track your submissions and make sure you are getting back what you expect based on the information you gathered.
Step 6: Repeat and Enjoy Your Reimbursements
Repeat Steps 4 & 5 with each claim and benefit from the deposits in your bank account!
So, is Therapy Worth the Cost?
Therapy costs money, and it may feel like a luxury or it may be something you hope to afford one day. But the truth is, the impact of not treating your mental health challenges will be far more expensive than regular therapy.
Consider my previous example—you spent $3,600 or more on therapy last year. That might seem like a lot, but then imagine that your marriage ends. Your divorce alone will cost more than $3,600, and now you have to pay the mortgage and childcare costs alone. Those costs are far greater. Or, imagine you need to take short-term disability to address a mounting physical or mental health crisis – chances are that will easily surpass $3,600 in lost wages and incurred medical costs in just a month or two. Or, imagine you lose an important relationship with an adult child, your best friend, or a parent due to poor communication skills, defensiveness, or emotional dysregulation. We cannot put a fixed price on that.
Conclusion: Investing in Your Wellbeing
So, bottom line, yes, counseling is worth it. You deserve to feel better. Shopping on Amazon, going out for pizza and happy hour, weekend getaways to escape reality, and gambling… these things give you temporary relief followed by feelings of guilt, shame, and despair. Therapy creates long-term change, not temporary feel-good moments.
This blogpost was originally posted here!
Please note that the blogpost above does not represent the thoughts or opinions of Fresh Start Registry and solely represents the original author’s perspective.