What Is An Out-Of-Network Psychiatrist?
So you’ve found a psychiatrist that seems like a great fit. That's so important for such a personal area of medicine, but there's a problem.
Apparently, they’re “out-of-network.” So what does that mean? Depending on your insurance policy, you might be reimbursed for a portion of the cost of seeing an out of network psychiatrist, but only a portion.
What Does It Mean for a Psychiatrist to Be Out-Of-Network?
If a psychiatrist, or any healthcare provider, is out of your insurer's network, it means they have not established a contract with your insurance company. If a physician is within your insurance network, they can be paid by your insurer directly.
If you're seeing an out-of-network mental health provider, then you will have to pay them directly, though you might be able to be partially reimbursed if your insurance plan features out-of-network benefits.
What Are “Out-Of-Network” Benefits?
Out-of-network benefits are provided as part of some insurance plans to let you see clinicians who may not be in your insurance company’s network. Instead of the insurance paying the clinician directly, they reimburse you for a portion of the cost.
Usually, this requires submitting a “superbill" to your insurance company.
What Is A Superbill?
A superbill is an itemized receipt of services issued by a healthcare provider. The superbill can then be submitted to your insurance company, assuming your health plan offers out-of-network benefits, to begin the reimbursement process.
The amount you are reimbursed depends entirely on your health insurance plan, but many plans will reimburse up to 50-80% of the allowed amount for psychiatry visits after meeting the out-of-network deductible.
OK, now you might be wondering what those words mean.
What Is A Deductible?
A deductible is a certain amount that you must pay in a given year before your insurance company's reimbursement rates start kicking in.
For example if you have a health plan with a $1000 deductible, then you'll need to make at least $1000 of out-of-pocket payments before your insurance company will begin paying their part of your medical bills.
Note that there are some additional wrinkles here. Preventative care, like your annual office visits to your primary care physician for check ups and vaccines, may be fully covered by your health benefits.
What Is An Allowed Amount?
An allowed amount will impact what percentage of an insurance claim will actually be reimbursed. Health insurance plans operate on “reasonable and customary” fees, often based on Medicare reimbursement rates. It may not necessarily be reflective of what you paid.
For example, if you were charged $400, but the insurer’s allowed amount is $300, the reimbursement would be 50-80% of $300.
Unless you've already hit your out-of-pocket limit.
What Is An Out-Of-Pocket Limit?
An out-of-pocket limit is the maximum amount you'll have to pay in a given year as you're seeing physicians in your provider network.
For example, if your health plan has an out-of-pocket limit of $5000, then once you've paid that amount in a given year, your covered insurance claims will be reimbursed in full beyond that amount.
Note that even if you have out-of-network benefits, you will still likely only receive partial reimbursement for out-of-network mental health providers, EVEN IF you've hit your out-of-pocket limit for a given year.
How Do I Find Out What My Health Plan Covers?
Before starting treatment, it’s helpful to call your insurance provider. Use the number on the back of your insurance card and ask the following questions:
Do I have out-of-network benefits for mental health?
Do I need prior authorization? If so, how do I obtain it?
What is my deductible, and how much of it has been met? Do I have a co-pay?
What percentage of the fee will be reimbursed once I meet my deductible?
Where do I send claims for reimbursement? Can I do it online or by mail?
Do I need a specific claim form? Where can I access it?
Before ending the call, make sure to write down the name of the representative, the date, and a reference number for the call.
How Is Reimbursement Handled at EZ Psychiatry?
At EZ Psychiatry, we believe in thoughtful, individualized psychiatric care. By choosing not to work with insurance companies, we can focus solely on delivering the highest standard of care without the limitations often imposed by third-party payers. You can read about our philosophy to learn more.
Patients pay directly at the time of service, then, upon request, we can provide a superbill that contains the necessary details for insurance reimbursement. This typically includes
Diagnosis codes (ICD-10)
Procedure codes (CPT)
Session date, time, and fees
Clinician credentials and contact information
What Are the Most Commonly Billed Services?
CPT code 90792 - Psychiatric diagnostic evaluation with medical services
CPT code 99214 - Evaluation and management of an established office patient
CPT code: 99214 + 90836 - Evaluation and management of an established office patient with 45-minute psychotherapy
CPT code: 99214 + 90833 - Evaluation and management of an established office patient with 30-minute psychotherapy
Why Do Psychiatrists Choose To Offer Out-Of-Network Care?
Choosing out-of-network care gives clinicians the freedom to prioritize what matters most: your mental health. Without the constraints of insurance, you often benefit from longer sessions, greater access to your doctor, more individualized attention, greater privacy, and more flexibility in your treatment plan.
Still Have Questions?
Contact us at info@ezpsychiatry.com or visit www.ezpsychiatry.com to learn more about our specific services, fees, and what to expect from your first visit.
