Clarity on Insurance: What's the real cost of treatment?
Updated: May 19
Don't quit before you start! When you pay out a hefty amount of money each month for your health insurance, you want to be able to use it for your healthcare services. Therapy is a healthcare service that people often want to guarantee is covered by their insurance plan before scheduling that first appointment. For most people, choosing to start seeing a therapist is already such a difficult step. So many thoughts and feelings come up…
“I shouldn’t need this; I should be able to handle this on my own”
“Why do I need someone else to solve my problems?”
“Many people have it worse than I do – they need therapy more than me”
“I’m not crazy”
“What will people think if they find out?”
“It’s not really going to help anyway”
Unlike other healthcare services, there can still be still stigma, guilt, and shame attached to seeking mental health services. Add on top of that the idea that your insurance may not cover the cost – most give up on therapy before they even get started.
Let’s break down the insurance game a little bit here. HMO, PPO, EPO, and POS – what does all of this mean? If you have an HMO plan (Health Maintenance Organization), this means you need to stay within your designated network for any healthcare costs to be covered. However, if you chose a PPO plan (Preferred Provider Organization), you have the option to go outside of the "preferred", in-network provider list. With a PPO plan, you are able to choose your own provider and your plan will cover some of the cost of treatment. EPO plans (Exclusive Provider Network) are similar to an HMO in that your costs will not be covered if you go outside of the designated provider list. POS are similar to a PPO in that you can see a provider outside of the network, but you will need a referral from your primary care physician. Let’s talk about the PPO and POS plans, in particular.You have chosen to pay more for this type of plan so that you have the freedom to choose your healthcare provider, so take advantage of this flexibility that you have! Consider an out-of-network therapist if you find one that feels like the best fit for you.
Why are so many therapists out of network? One reason is because of the low rate that insurance companies choose to reimburse in-network providers. These rates paid to in-network providers are often well below fair health consumer rates and have not increased through the years. Check out Fair Health Consumer for more details about fair rates in your geographic area. To view therapy rates, you can enter billing codes 90837 or 90834. This will give you more information on in-network and out-of-network rates and average insurance reimbursement rates. Aside from low reimbursement rates to providers, there are many other reasons that therapists choose to remain outside of a managed care network. The decision to remain out-of-network is often because we do not want insurance to manage your care! Therapy is a deeply personal experience and requires personalized service to meet the needs of each individual seeking care. This means that you want to find the right fit in a therapist and experience these benefits:· You deserve to choose someone that you feel connected to and not have limitations of insurance choosing your therapist.· It is important for you to find a specialist in your particular area of struggle, who has the proper training and experience to help you.· You should be confident that there is not a third party deciding if you really need this help. Insurance companies usually require in-network providers to call them for an authorization to determine if therapy is really necessary.· You will have comfort in knowing that the expert – your therapist – determines your length of treatment in partnership with you, rather than having the insurance company dictate how long you need by acquiring personal details of your treatment. · You are able to start talking to someone as soon as you decide you are ready! Because contracting as an in-network provider can be so challenging for therapists, the in-network options are limited and it may take time to get in to see a therapist who is contracted with your insurance company
Follow these 7 steps: When you are looking for a therapist, you may initially skip over anyone who says they do not accept insurance without even calling to inquire about his/her services. That therapist may be the BEST person for you, but there is no opportunity to know until you have a conversation. Before you choose to skip over any out-of-network provider, consider following these steps to gather more information:
1) Get really familiar with your insurance plan! You pay good money for this plan, so take time to fully explore the benefits and options that are available to you. If you have a printed copy or access to your policy via online portal, take time to thoroughly read through your policy in order to understand your costs and financial responsibility.
2) Call your insurance company and ask for more details about your out-of-network benefits. Confirm your financial responsibility if you go to an out-of-network provider. Make sure you understand your out-of-network deductible and cost share (the percentage you are responsible for), and ask them directly what they will reimburse you if you go to an out-of-network therapist. Insurance companies typically use the term “Usual, Customary, and Reasonable Charges” without giving a specific rate. Ask for a specific rate of reimbursement and if they require a billing code, use either 90834 (45 minute therapy session) or 90837 (60 minute therapy session).
3) Calculate your actual net cost for seeing the out-of-network therapist you have found. For example, your therapist may charge $175 per session that you pay up front at the time of service, but your insurance company tells you they will reimburse you $115 per session for an out-of-network therapist, so your real net cost will be $60 per session.
4) Check out some of the services that are now available to help with reimbursement. You can submit your claims on your own, but if that feels too overwhelming, there are now services available to help. Check out these options (GetBetter, Claimeye, Reimbursify).
5) Understand that using insurance – either in or out of network – does require the submission of paperwork that includes a diagnosis. This is how the insurance company manages your care by determining that your diagnosis is worthy of treatment. After doing research, you may decide that you do not want to use insurance at all in order to protect your privacy and be free from third party involvement in your care.
6) Take a look at your expenses and consider other areas where you are currently spending that could be reduced in order to provide this important self-care and healing opportunity. Consider what it will cost if you do NOT get the proper treatment.
7) Schedule an appointment! It is important that you get the help that you need. There are good therapists in-network and going out-of-network may not be an option if your finances are tight. This information provided is for you to understand and explore your options that your insurance plan provides you so that you can make educated choices. Whether you need to stay with an in-network therapist or decide to explore outside of your insurance network, the ultimate goal is to get your therapy session scheduled.
What is the cost of not engaging in therapy? You are seeking help because you are suffering in some way. How will your life change if you do nothing and continue to suffer? How will your life change if you get the help and guidance that you need? Investing in yourself, caring for your mind as well as your body, can have significant impact on your quality of life that is well worth the cost. Most people dealing with a physicalhealth issue will go to great lengths to make sure they get the care and treatment needed to recover and fully restore their health. Mental health should be equally important and it is vital to work with a qualified professional that you feel a connection with, who can walk through your challenges with you, and help you heal.
Anissa Bell, LMFT, Clarity Therapy Associates, San Diego CA