How Does the Out-Of-Network Reimbursement Process Work?

I am a fee-for-service, private pay therapist, which means that you are responsible to pay the fee for each session at the time of the session. Many of my clients pay for their therapy with their health savings account or flexible spending account, while others pay with cash or credit card.

I am considered an out-of-network provider for all insurance plans. If your insurance plan includes mental health benefits and if you’re wanting to seek out-of-network reimbursement from your insurance company, it’s important for you to understand how the process works and what it requires, along with its disadvantages and potential benefits, so that you can make an informed decision about whether it’s the route you want to pursue or not.

At a minimum, seeking reimbursement from your insurance company requires that you meet criteria for a mental health disorder diagnosis. I can assess you for such a diagnosis if you request this of me up front. This assessment is something that usually takes a few sessions to complete. If you meet criteria for a mental health disorder diagnosis, that diagnosis will then be put on your permanent medical record when you submit for out of network reimbursement. After you submit your diagnosis on a superbill which I can provide you (containing information about the therapy services you’ve received), your insurance company will make a determination of whether they believe therapy is a “medical necessity” for you.

If the insurance plan decides therapy is a medical necessity for you, your plan will then notify you directly of the amount of therapy services for which they will reimburse you and number of sessions they will allow, which reimbursement usually applies after you have met have your deductible in full. These specifics vary by insurance plan. There is also a chance that you will go through that process and your insurance plan will decide that therapy is not a “medical necessity” for you.

Most insurance plans don’t cover couples therapy to address relationship issues. However, if you're interested in having your insurance help pay for your couples therapy, I'd recommend you call your plan and ask them specifically whether they cover couples therapy without giving one partner a mental health disorder diagnosis.

One of the most important things for you to know about this process is that if you choose to submit for reimbursement from your insurance company, this subjects my records about you to the requirements of the insurance company and waives your rights to privacy and confidentiality as if I were paneled with the insurance company.

It is also important for you to know that the therapeutic services I provide are based on what I determine—based on my clinical training, experience and judgment and the collaborative process of working with you—will best assist you in meeting your therapeutic goals. My focus is on doing what seems to be in your best interests and will provide the maximum benefit to you—not necessarily on what particular diagnosis, treatment modality or session structure an individual insurance plan may be willing to reimburse.

It is your responsibility to find out and follow your plan’s policies in the process of seeking out-of-network reimbursement. Insurance companies have many rules and requirements specific to each individual plan and do not make it easy to obtain reimbursement.

As a result of the above factors and others, the majority of my clients choose not to seek reimbursement from their insurance plan, because they decide that the disadvantages of the insurance process outweigh the potential benefits, and they want to keep everything they share with me confidential and all decisions about the therapy process to be made by them and me.

During your phone consultation, I will get some information from you in order to briefly assess your situation and then recommend the type of therapy I believe will be most beneficial to you. I will share with you the set session fee for that type of therapy at that time so you know what to expect.