How to Use Out-of-Network Benefits for Therapy
Many people don't realize they can use their insurance benefits even with therapists who aren't "in-network." As an out-of-network therapist provider in Seattle, I've helped hundreds of clients get reimbursed for a significant portion of their therapy costs. Let me guide you through understanding and maximizing your out-of-network benefits.
Understanding Out-of-Network Benefits
What Does Out-of-Network Mean?
In-Network Providers
Contract directly with insurance companies
Accept negotiated rates
File claims for you
Limited to insurance requirements
May have session limits
Out-of-Network Providers (Like Me)
No insurance contracts
Set own rates
You file for reimbursement
More treatment flexibility
No insurance-mandated limits
Why I Choose Out-of-Network Status
Clinical Freedom
Treatment based on your needs, not insurance protocols
No required treatment plans for review
Privacy of your records maintained
Length of treatment determined clinically
No pressure to use specific diagnoses
Quality of Care
More time for each client
No insurance paperwork during sessions
Focus entirely on your healing
Flexibility in approaches used
No sudden insurance-driven termination
How Out-of-Network Benefits Work
The Basic Process
You Pay Me Directly
$250 per session at time of service
Credit card, check, or HSA/FSA
I Provide a Superbill
Detailed receipt with required codes
Monthly or per-session basis
All information insurance needs
You Submit for Reimbursement
Send superbill to insurance
Usually online or mobile app
Sometimes by mail
Insurance Reimburses You
Direct deposit or check
Based on your plan's coverage
Usually within 2-4 weeks
Typical Coverage Amounts
While every plan differs, common scenarios include:
PPO Plans Often Cover:
60-80% after deductible
Example: $250 session → $150-200 reimbursed
Your cost: $50-100 per session
High-Deductible Plans:
Full cost until deductible met
Then 60-80% coverage
HSA can cover pre-deductible costs
EPO/HMO Plans:
Usually no out-of-network benefits
Some exceptions for mental health
Worth checking your specific plan
Essential Questions for Your Insurance
Before Starting Therapy
Call your insurance and ask:
Coverage Questions:
"Do I have out-of-network mental health benefits?"
"What is my out-of-network deductible for mental health?"
"Has any of my deductible been met this year?"
"What percentage does insurance cover after deductible?"
"Is there a maximum reimbursement rate per session?"
"How many sessions are covered per year?"
"Do I need a referral or pre-authorization?"
Reimbursement Questions:
"How do I submit claims for reimbursement?"
"Can I submit claims online?"
"How long does reimbursement typically take?"
"Is there a deadline for claim submission?"
Getting Clear Answers
Be Specific:
Ask for mental/behavioral health benefits specifically
Request out-of-network coverage details
Get information in writing if possible
Ask for reference numbers
Key Terms to Know:
Deductible: Amount you pay before coverage starts
Coinsurance: Percentage you pay after deductible
Allowed amount: Maximum insurance will consider
Balance billing: Difference between my fee and allowed amount
Maximizing Your Benefits
Strategic Timing
Calendar Year Considerations:
Deductibles reset January 1st
Starting mid-year may mean met deductible
Plan for year-end therapy continuation
Consider intensive work when deductible met
FSA/HSA Planning:
Estimate annual therapy costs
Maximize tax-free contributions
Use for pre-deductible expenses
Effective 20-30% discount
Documentation Tips
Keep Records Of:
All superbills provided
Claim submission confirmations
Insurance correspondence
Reimbursement amounts
EOBs (Explanation of Benefits)
Organized System:
Digital folder for documents
Track submission dates
Note reimbursement amounts
Annual summary for taxes
Common Insurance Scenarios
Scenario 1: Good PPO Coverage
Your Plan:
$500 out-of-network deductible
70% coverage after deductible
You've met $300 of deductible
Your Costs:
Next 2 sessions: Full $250 (meeting deductible)
Subsequent sessions: $75 (you pay 30%)
Annual savings: Approximately $7,000
Scenario 2: High-Deductible Plan
Your Plan:
$3,000 deductible
80% coverage after deductible
HSA contribution maxed
Strategy:
Use HSA for all sessions
Submit claims to meet deductible
Other medical costs may help meet deductible
Eventually get 80% coverage
Scenario 3: Limited Benefits
Your Plan:
No out-of-network coverage
Or very limited reimbursement
Options:
Use HSA/FSA for tax savings
Check employer wellness benefits
Consider private pay value
Explore other funding sources
The Superbill I Provide
What's Included
Every superbill contains:
My practice information and NPI
Your demographic information
Dates of service
CPT codes for services
Diagnostic codes
Session fees
My signature
CPT Codes I Use
90791: Initial diagnostic evaluation
90834: 45-minute psychotherapy session
90837: 53+ minute psychotherapy session
90834-95: Telehealth modifier when applicable
Privacy Considerations
Required Diagnosis: Insurance requires a mental health diagnosis for reimbursement. I use:
Least stigmatizing accurate diagnosis
Clinically appropriate codes
Discussion with you first
Privacy-conscious approach
Step-by-Step Reimbursement Guide
1. Verify Your Benefits
Before our first session:
Call insurance member services
Ask questions listed above
Get representative's name
Document what they tell you
2. Set Up Your System
Create insurance folder (digital/physical)
Set calendar reminders for submission
Know submission deadlines
Have insurance portal login ready
3. After Each Session
Receive superbill (monthly or per session)
Pay my fee directly
Keep payment receipts
File superbill promptly
4. Submit Your Claim
Online Submission (Preferred):
Log into insurance portal
Find claims submission
Upload superbill
Submit with any required forms
Mail Submission:
Complete claim form
Attach superbill
Keep copies
Send certified if large amount
5. Follow Up
Check claim status online
Call if no response in 30 days
Appeal any denials
Track all reimbursements
Common Problems and Solutions
Claim Denied
Possible Reasons:
Missing information
Diagnosis not covered
Benefits exhausted
Timely filing issue
Solutions:
Appeal with additional info
Correct and resubmit
Call for clarification
I can provide revised superbill
Low Reimbursement
Why This Happens:
"Usual and customary rate" limits
Out-of-network rate schedules
Geographic adjustments
What to Do:
Appeal with fee documentation
Highlight my specialized training
Request case review
Accept what's offered
Processing Delays
Typical Causes:
High claim volume
Additional review needed
System issues
Your Response:
Call after 30 days
Get claim reference number
Request expedited processing
Stay persistent
Is Out-of-Network Worth It?
Benefits Beyond Reimbursement
Even with partial reimbursement, you get:
Choice of specialist
No insurance interference
Complete privacy
Flexible treatment
Higher quality care
When It Makes Sense
You want specialized treatment
Privacy is important
You can manage initial costs
Quality matters to you
Long-term value recognized
Working Together
My Support
While I don't file insurance, I:
Provide detailed superbills
Answer insurance questions
Revise documentation if needed
Support appeals if necessary
Make process smooth
Your Responsibility
You'll need to:
Understand your benefits
Submit claims timely
Track reimbursements
Manage the financial flow
Communicate any issues
Ready to Explore Your Benefits?
Don't let insurance confusion prevent you from getting help. During our free consultation, we can:
Review your benefits situation
Calculate potential reimbursement
Discuss payment strategies
Determine if this works for you
Many clients find they can afford quality therapy through smart use of out-of-network benefits. Let's see what's possible for you.
