Reimbursement 101: Navigating Insurance for Out-of-Network Therapy
Investing in your mental health is one of the best decisions you can make, but the financial side of therapy can sometimes be overwhelming and discouraging. While in-network providers might seem like the easiest path, venturing into the world of out-of-network therapists can offer you greater freedom and a chance to work with someone who truly gets you. And guess what? It doesn’t have to break the bank! Many insurance plans offer reimbursement for out-of-network services, making therapy more affordable and personalized than you might expect.
What Are Out-of-Network Benefits?
Out-of-network benefits let you see a therapist who isn’t contracted with your insurance provider. There’s many reasons why a therapist may opt to remain out-of-network but most of those reasons can be boiled down to avoiding the red-tape rodeo of insurance companies in order to focus on what really matters – you.
When working with an out-of-network therapist, you pay upfront for sessions and submit a claim to your insurer for reimbursement. Insurance companies often cover 50–70% of the session fee (sometimes even more!), significantly reducing your out-of-pocket expenses.
For example, if your therapist charges $150 per session and your insurance reimburses 60%, you’d get $90 back per session – leaving you to pay just $60. This can make working with an out-of-network therapist a no-brainer, especially if finding someone who aligns with your goals and values is your top priority.
How to Get Started with Your Out-of-Network Benefits
First things first: crack open your insurance policy (or call your provider) to learn about your out-of-network deductible and coinsurance for mental health services. You can find the insurance company’s phone number on the back of your card. Got a healthcare navigator or navigation platform at your disposal? They’re like your personal sherpa through the insurance mountains, ready to help you figure it all out.
Key Questions to Ask Your Insurance Provider:
Has my deductible been met this year?
What is my out-of-network deductible for outpatient mental or behavioral health?
Are there session limits?
Do I have coinsurance and if so, how does it work?
Do I need a referral to see an out-of-network therapist?
What’s the process for submitting claim forms to get reimbursed?
With answers to these questions in hand, you’ll be well on your way to making the most of your benefits and navigating the process like a pro.
What Is a Superbill?
Think of a superbill as your backstage pass to insurance reimbursement. It’s a detailed receipt from your therapist that has all the info your insurance company needs to process your claim. Here’s a list of everything that should be included:
Provider Name: Your therapist’s name
Provider Address: The official address of your therapist’s practice.
Tax ID: Their Tax Identification Number for billing.
Procedure Codes (CPT or HCPC): Codes that explain what type of service you received.
Units for Each Procedure: How many times a service was provided (ex. 1 session = 1 unit).
Diagnosis Codes: These show why you’re seeking care. (Chat with your therapist about the appropriate diagnosis for your treatment and reimbursement.)
Patient Name: That’s you — or whoever received the service.
Service Location: Where the session(s) took place (ex. in-office, virtual, etc.).
Date of Service: When your session(s) happened.
Billed Amount: How much your therapist charged.
Amount Paid: What you’ve already paid out-of-pocket.
National Provider ID (NPI): Your therapist’s unique ID number.
Step-by-Step Breakdown
Review Your Insurance Policy: Understand your out-of-network benefits — things like deductibles, coinsurance, and reimbursement rates.
Request a Superbill: Ask your therapist for one if they don’t provide it automatically.
Submit Your Claim: Follow your insurer’s steps for claim submission. Many offer online options making it quick and easy.
Track Your Reimbursements: Keep an eye on your insurance statements to ensure your claims are processed correctly.
Why Choose an Out-of-Network Therapist?
So, why go out-of-network when in-network options exist? Great question! The answer really comes down to freedom and fit.
Out-of-network therapists aren’t restricted by insurance company rules, giving them the flexibility to tailor their methods, session lengths, and scheduling to fit your unique needs. This personalized approach allows you to focus on long-term healing with a therapist whose allegiance is with your goals and values—not the budget and antiquated practices of an insurance company.
Yes, submitting claims takes an extra step, but it’s worth it to prioritize your mental health. And remember, if you ever feel stuck, I’m here to guide you every step of the way. Your mental health is worth the investment!