How do you see a therapist that is out of network?

It’s a story I’ve heard more than once. A client really wants to see me as their therapist, but I am not in-network for their insurance company. Now their choice is either to pay out of pocket to see me (a potentially expensive proposition) or find someone else. You may be surprised to learn that there are a couple of ways you can get your insurance company to pay for seeing the therapist you want to see that is out of network.

One option is paying out of network (OON). Many insurance companies will allow a client to see a therapist that is not in network by arranging out of network reimbursement. Here’s how it works: contact your insurance company and ask for them to cover your visit to the therapist as an “out of network provider”, then you pay the therapist their full fee when you see them, and if your deductible is met the insurance reimburses you for much of your fee. Typically a therapist like me would give you an invoice or “superbill” and you mail it to your insurance for the reimbursement. In my experience you will get back about 50-60% of what you would pay. If your deductible for the year is not met you don’t get any reimbursement, but your payment would still go toward your deductible.

A better option would be arranging a Single Case Agreement (SCA). A Single Case Agreement is a one-time contract between an insurance company and an out-of-network provider for a specific client (you), so that the patient can see that provider using their in-network benefits. In this scenario you would only pay the therapist the coinsurance or copay you would normally pay for a visit, even though he or she is out of network. SCA’s are usually for instances where you need to see someone who has specialized skills that their in-network therapists don’t possess, or if going to the nearest in-network specialist is out of your geographic region and to see them would be burdensome.

For example if you have PTSD and want to see a therapist who is certified in EMDR, a specialized therapy for trauma, and there aren’t other local in-network providers who do this, you can ask your insurance company to make an SCA in order to see him. You can also request an SCA if you have been seeing a therapist for a while but your insurance has changed, and he is not in network for your new insurance. In that case it’s important to continue with your therapist to preserve the “continuity of care.” Again, the great benefit with SCA’s is that you are only paying your normal copay.

A third option could occur in cases where a therapist is in network for some plans but out of network for others. For example I am in network for Kaiser Permanente PPO plans, but not the HMO plans. In this case if you had the HMO plan you could call your insurance and ask them for authorization to see the therapist. Insurance companies are typically very willing to do something like this, I haven’t seen a client turned down yet.

A sliding scale is a final possibility. Some therapists are willing to lower their normal fee in order to accommodate those who would face significant financial hardship to pay a therapist’s full fee on a regular basis. It’s always worth asking about if there are no other options available.

Insurance is complicated, and frankly nobody likes how it works. The important thing to remember is that you have rights and you have options! Hope this helps.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s