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 should be able to handle this on my own
Many people have it worse than I do – they need therapy more than me
I’m not crazy
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 - it's tempting to give up on therapy before you 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 more freedom to choose your healthcare provider, so take advantage of this flexibility that you have! Consider therapists outside of the insurance "preferred provider network" to 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. The rates paid to in-network providers are often well below fair health consumer rates and have not increased appropriately 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/CPT code 90837. 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 not contract with an insurance company is often because we do not want insurance to manage your care! Therapy is a deeply personal experience and requires individualized attention to meet your needs. It is important for you to find a specialist in your particular area of struggle, who has the proper training and experience to determine your course of treatment. Insurance companies usually require in-network providers to call them for an authorization to determine if therapy is really necessary, and they also may determine the number of sessions allowed. Although paying out of pocket is costly, you will have comfort in knowing that your therapist determines your length of treatment in partnership with you, rather than having the insurance company managing your care. 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. 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 pass over an 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 an 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 CPT code to give you these details, 90837 and 90834 are commonly used billing codes for therapy.
3) Calculate your actual net cost for seeing the out-of-network therapist you have found. For example, your therapist may charge $200 per session that you pay up front at the time of service, but your insurance company tells you they will reimburse you $120 per session for an out-of-network therapist, so your real net cost will be $80 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. Here are a few examples: GetBetter, Claimeye, Reimbursify
5) Understand that using insurance does require the submission of personal information that includes a diagnosis. Your 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 money. Review costs that could be reduced in order to provide this important self-care and healing opportunity. Consider the cost to your functionality and overall wellbeing if you do NOT get the proper treatment.
7) Schedule an appointment! It is important that you get the help that you need. If your finances are tight, paying out-of-pocket for your therapy may not be a possibility. The information provided here is to help you understand and explore your options so that you can make educated choices. Whether you need to work with a therapist fully covered by your insurance or you are able to explore providers 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 investment. Most people dealing with a physical health 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 care is equally important for your overall wellbeing.
Anissa Bell, LMFT, Clarity Therapy Associates, California
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