How to Use Your Insurance To See An Out-of-Network Provider

It can be very difficult to afford therapy and other mental health services. If you are lucky enough to have healthcare that includes mental health benefits, then you may occasionally come across another problem.

Imagine this scenario. You search and search for the right therapist for yourself, your partner, or child. After calling several offices, and searching high and low, you finally find the perfect therapists here (shameless plug alert)! But to your dismay, their office does not accept your insurance. Now you’re probably thinking that you will have to continue the search for another therapist. Not necessarily! A little known secret is that some insurance plans (an estimated 28%) provide limited benefits for you to see providers who are not within network for your particular plan.

Here is an example.

You are currently covered by a Humana Healthcare plan. For mental health services (such as outpatient therapy), you pay a copay of $40 and your plan covers the remaining costs as long as you see a provider who is within their network. If, on the other hand, you want to see a provider who is not within network, then there are a few things you can do:

1. Look up your current insurance plan’s benefits. You can do this by logging into your insurance plan’s client portal. If you are unable to do this then just call the member number on the back of your card.

2. Explain to the representative that you are trying to see a provider who does not accept your insurance and wanted to know about your plan’s specific “Out-of-Network (OON) benefits.”

3. The representative should provide a detailed explanation of your plan’s OON benefits as well as how you will go about submitting claims for reimbursement. Contact the office of the provider you are trying to see for therapy to discuss how you can use your OON benefits to cover any sessions.

Getting back to our example, let’s say that the customer service rep says that your insurance plan will reimburse you for 40% of the costs of services provided by an out of network provider. You contact the therapist’s office and learn that one session of therapy will cost approximately $250. For each session you see the therapist you will pay their office the $250 upfront. Their office will then provide you with a document called a superbill which is basically an itemized invoice for the session.

Your job is to then submit the superbill to the insurance company directly for reimbursement. At a 40% reimbursement rate you will get back a check in the amount of $100. Given that you initially paid $250, you will have ultimately paid $150 for the therapy session. We hope that this post enables you to use your plan’s OON benefits to see therapists who may not be in-network for you. If, on the other hand, your plan does not provide out of network benefits, then contact our office to learn more about our self-pay rates or click here to find a provider who does accept your insurance.