A special note on insurance reimbursement

Prospective clients often unknowingly limit their provider options based on lack of information about the insurance system. Trust me, I didn’t know much about it either until I needed to! It’s all about the Out of Network (OON) benefit.

While I am not paneled with any health care insurers, I see clients with a range of health insurances, as well as those who choose not to use health insurance. Insurance payers will understandably encourage you to see a provider who is in their network, and typically these visits will entail a copay paid by you. Even for clients seeing an in-network provider, more and more clients have insurance plans with high deductibles, meaning clients are responsible for meeting all costs until the deductible is met.

Be sure to call your insurance payer or look at your benefits package to see if you have an OON benefit. When there is an OON benefit, clients can submit a reimbursement claim to their insurance for partial payment of services. The net amount the client pays out of pocket may still be more than their copay with an in-network provider, but for many clients the benefit of seeing their preferred provider outweighs the difference in cost. Many clients don’t know about or don’t understand OON benefits, leaving them searching unsuccessfully for the right in-network provider only because they don’t understand their options.

Some examples to illustrate:

Scenario A: John has health insurance through Sunnydale insurers. He sees an in-network therapist who charges $150 per visit, of which John pays a $40 copay per visit.

Total out-of-pocket cost to John after 20 sessions: $800

Scenario B: John has health insurance through Sunnydale insurers. He sees an in-network therapist who charges $150 per visit, of which John pays a $40 copay per visit, but only after meeting a $3000 in-network deductible.

Total out-of-pocket cost after 20 sessions: $3000

Scenario C: John has health insurance through Sunnydale insurers. He sees an out-of-network therapist who charges $150 per visit, which John pays directly to the therapist. John then submits a reimbursement claim to Sunnydale, which reimburses him $100 per visit, leaving John with a total per-visit cost of $50.

Total out-of-pocket cost after 20 sessions: $1000