Out of Network Benefits

This is a term you've probably heard of before but may not be exactly sure what it is.  

I have seen countless therapists advertising on their Psychology Today profiles that they are Out of Network Providers for the various insurance companies. This gives the consumer the impression that their insurance will cover services provided by these clinicians. But that’s not necessarily the case. 

Out of network refers to providers or services that are not on panel with a specific insurance company. For example, if you are not paneled with Blue Cross Blue Shield (BCBS), you are considered an out of network provider for BCBS. Even though you may be on other insurance panels (Aetna or Cigna) but not on BCBS. You would be considered out of network for BCBS because you don’t have a contract with BCBS.

Many wonder if insurance will pay for out of network services or benefits. And the answer is not necessarily. When people hear the term benefits, it sounds like it is somewhat covered by insurance. But that’s not a guarantee. And if the client does not have out of network benefits, it becomes the client’s responsibility to pay out of pocket for the services. 

Some insurance plans, typically PPO’s, will reimburse for out of network provider services. If your client's insurance plan does offer out of network benefits, chances are that the reimbursement rate, copay, co-insurance, and/or deductible is different from in network providers. Sometimes it can be a higher rate than for providers who are in network.  

Some providers will list on their websites that they accept out of network benefits which makes it sound like their services will be covered by insurance. But that can be misleading.

Typically, HMO insurance companies do not offer out of network benefits, or if they do it will have a high deductible (think $5,000 to $10,000). A deductible is the portion a client must pay out of pocket before insurance will start to pay a portion for the services.

The only way to be certain if an insurance company will pay for out of network benefits is to call the insurance company and ask specifically if the member has out of network benefits. 

Insurance will not process a claim, even an out of network claim, if it does not meet the criteria for them to be able to process the claim. There are a few key pieces of information needed in order to submit a claim to insurance.

That said, to be able to access out of network benefits, the clinician would have to provide a diagnosis, CPT code, date of service, place of service, office/billing address, NPI and tax ID. Some providers that are not on insurance panels do not give diagnosis. It is not required to diagnose clients if you are not filing insurance claims. Therefore, this is something the clinician will want to take in consideration when agreeing to submit bills to insurance for out of network services. 

It’s important to understand what out of network benefits actually means so that you can discuss this with clients who want to use their insurance with a provider who is not on their insurance panel.

No one likes to be surprised by a big bill.

If you are able to access out of network benefits. That’s great!

When calling insurance about eligibility and benefits, make sure to get an authorization or reference number, the number of sessions to be covered, the CPT codes that will be covered, the client’s responsible portion, and the dates for when this authorization code is valid. Sometimes the authorization will be for a few months or it can extend to a calendar year. 

Some therapists will ask their clients to pay out of pocket for services and give the client a receipt. This receipt is often called a superbill. The client can then send in the superbill to their insurance for reimbursement. Keep in mind that the insurance will still need those basic pieces of information (diagnosis, CPT code, amount paid, date of service, NPI and tax id) to be able to reimburse the client. 

It’s always a good idea to understand what the terms or conditions are to be able to submit bills to insurance for payment. You can help your clients make an informed decision about what to expect if they want to submit the bill to insurance.

I see a lot of questions about out of network benefits, billing, and reimbursement. I hope this answered some of those questions. 

As a Psychologist with a thriving business, I believe that owning an insurance based private practice is the key to financial freedom, professional freedom, and personal freedom. If you have questions or need help creating your own practice, contact me at Robin@DrRobinMyers.com. I offer Coaching and Consulting Services.

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