Out-of-Network Insurance FAQ

Understanding insurance can be complicated and can feel overwhelming! The following information may be useful in figuring out how your insurance plan works.

1) Insurance plans that allow you to see out-of-network providers (often called PPO plans) usually reimburse you a certain portion of the fee you pay to an out-of-network clinician. PLEASE NOTE: Every insurance plan's reimbursement rate is different. Even if you have the same insurance company as someone else, if you have different employers, your reimbursement rate might be different. In addition, you may have a deductible that you will have to meet before you begin to receive reimbursements.

2) To find out the exact rate of reimbursement (and whether you have a deductible), you can call the number on the back of your insurance card. The insurance company may also need information such as clinician name and address, which you can find on my contact page. Below is some information that may be useful.

• You are asking about seeing an "out-of-network behavioral health clinician"

• The clinician's degree is: Clinical Psychologist (Psy.D.)

• The clinician's fee is: $200

• The typical procedural code (CPT code) for psychotherapy is: 90834 (Individual Psychotherapy)

3) PLEASE NOTE: Often, insurance companies calculate reimbursement rates based on a fee value that THEY set, which may not be the same amount as the fee that the clinician charges. Be aware that you may only find out the exact amount of reimbursement after the first claim is processed.

Here is a hypothetical scenario, using a fee of $200:

• Insurance Company X decides that the value of a session of individual psychotherapy is $100. (This is called the "allowable amount".) The insurance company's reimbursement rate calculations will therefore be based on this number.

• Any remainder owed to the clinician over that amount is the sole responsibility of the client (in this example, $100).

• If you have a co-insurance responsibility of 20%, Insurance Company X will tell you that you will owe the clinician $20 (20% of $100).

• The final cost to you will be $120: $20 (co-insurance), plus $100 (the part of the fee that Insurance Company X does not recognize).

• Of the $200 fee, you would receive reimbursement from Insurance Company X for $80.

PLEASE NOTE:

I am not an insurance expert nor am I an insurance company representative! Always check with your insurance company about their policies and your specific coverage.

For more resources on understanding insurance and therapy, check out the Zencare FAQ on out-of-network therapy.