Using Out-of-Network Health Benefits
I am a private-pay, out-of-network provider. While I don't accept insurance directly, your insurance plan may have out-of-network (OON) benefits, which means that they may reimburse you for a portion of your session cost. There are several ways that you can access these OON benefits, which I will explain below.
1) I can provide you with a Superbill on a monthly basis for you to submit to your insurance company.
The way this works is that you would pay for your full session fee at the start of each session. At the end of the month I send you a Superbill (Receipt) that includes the information that your health insurance company requires, such as date of each session, service provided, cost, and a diagnosis*. You then take each Superbill and submit it yourself to your insurance company. The insurance company will then send the reimbursement amount directly to you (usually through a check). Reimbursement usually takes between 4-6 weeks, but this varies based on the insurance company. This is a great option for those who would prefer to submit the Superbills themselves and don’t mind paying the full session fee and waiting for reimbursement. See example below of how this would work in a “real life” situation.
2) You can use Thrizer to submit the Superbill on your behalf and only pay your estimated out-of-pocket cost at the time of session
I have partnered with Thrizer to handle the out-of-network process automatically for you. There are two options when using Thrizer. To use the option above, you will only have to pay a copay for our sessions, instead of paying my full fee and waiting for reimbursement. This typically allows clients to save, on average, 70% upfront on our sessions.
How this option works:
At the time of session, you would pay your insurance co-pay (after your deductible is met, if you have one), instead of the full session fee. I will automatically submit the Superbill for the session to Thrizer who then submits it directly to your insurance company on your behalf. This leaves Thrizer, a HIPAA Secure company, to deal with the insurance hassles and saves you time and frustration. Thrizer immediately pays the rest of the session fee to me and then waits for reimbursement from your insurance company, which saves you from having to pay out-of-pocket and then wait for reimbursement yourself. If you choose this option, Thrizer charges you 5% of the session cost (at time of session) for them to submit the Superbill, pay the reimbursement amount, and wait on repayment from the insurance company on your behalf. This is a great option for those who would prefer to not have to submit the Superbills themselves and who may not want to or be able to pay for the sessions in full and wait for reimbursement. See example below of how this would work in a “real life” situation.
3) You can use Thrizer to submit the Superbill on your behalf, but choose to pay the full session fee at the time of session and wait for the insurance reimbursement yourself
How this option works:
At the time of session, you would pay the full session fee at the start of each session. I will then automatically submit the Superbill for the session to Thrizer who then submits it directly to your insurance company on your behalf. This leaves Thrizer to deal with the insurance hassles and saves you time and frustration. Once your insurance company approves the claim, you will receive the reimbursed amount via direct deposit. If you choose this option, Thrizer charges you 1% of the session cost (at time of reimbursement) for them to submit the Superbill on your behalf. This is a great option for those who would prefer to not have to submit the Superbills themselves, but who don’t mind paying the full session fee and waiting for reimbursement. See example below of how this would work in a “real life” situation.
Example of each option:
Let’s run through an example using a session fee of $150 and an estimated reimbursement of $100.
Client submitting the superbill themselves (not using Thrizer):
Client pays the therapist $150 at time of session and requests a Superbill. Client submits Superbill to their insurance company and receives a $100 reimbursement check in the mail 4-6 weeks later.
Client uses Thrizer to submit Superbill and only pays their out-of-pocket costs:
Client pays just $57.50 to the therapist at time of session. They pay $50 which is the difference between the $150 session fee and the $100 reimbursement, plus a 5% fee of the session’s cost which is $7.50. The client doesn’t need to submit the Superbill or wait for reimbursement.
Client uses Thrizer to submit Superbill, but chooses to wait on reimbursement themselves:
Client pays the therapist $150 at time of session. The client doesn’t need to get the Superbill from their therapist or submit it to the insurance company, because Thrizer does that on their behalf. After the insurance company approves the claim, usually in a few weeks, Thrizer direct deposits $98.50 into the client’s account, the $100 reimbursement, minus a 1% fee of the session’s cost which is $1.50.
How to find out if you have OON Benefits:
Going through Thrizer:
Should you choose to go through Thrizer, during our intake process, I can help you verify if you have out-of-network benefits and how much your copay would be. You would create a Thrizer account (I will give you the needed link to do this) and input your insurance information. Thrizer will immediately tell you if you have OON Benefits, what your copay is, if you have a deductible, and if you have met it already. This process usually takes just a few minutes.
Contacting your Insurance Company yourself:
If you’d prefer to research your OON benefits on your own, you can contact your health insurance company and inquire about this to learn if this is an option for your plan. Some helpful questions to ask your insurance provider are:
• Do I have a mental or behavioral health policy with out-of-network benefits?
• Do I have an out of network deductible?
• How much of my out of network deductible has been met?
• What is the start date of the calendar year my out of network policy is based on?
• Do I need prior authorization?
• What is the coverage amount/percentage per therapy session?
• What is my responsibility/copay for each session?
• You can ask about reimbursement for CPT codes (these are the insurance codes therapists generally use on Superbills):
90791 (initial Assessment/1st session)
90837 (individual therapy)
90846 (family therapy without identified client present – ie, parent consults)
90847 (family therapy)
90853 (group therapy)
Although these are the general CPT codes used, please be aware that some sessions may fall under a different CPT code.
* Please note: Insurance reimbursement is not guaranteed and in order for insurance to reimburse you for mental health care, I must provide a mental health diagnosis and a treatment plan that is considered medically necessary. Your insurance company has the right to request your therapy session notes as well. If you do not meet diagnostic criteria, I will be unable to list a diagnosis code on the Superbill. This is not a requirement if you are paying for services out-of-pocket, without using your insurance.
For additional information on Thrizer, including FAQ, please visit their website at https://www.thrizer.com/for-clients