There are some reasons why folks may seek therapy outside of their insurance plan and pay out of pocket:
Insurance companies can occasionally audit client psychotherapy records to determine if a client is eligible for more sessions (among other reasons). Moreover, your psychotherapy records may be accessible to all other clinicians within the same health system that you utilize for your insurance.Meaning that the content or nature of your mental health sessions may be seen by other providers like your in-network , Primary Care Physician, OBGYN, podiatrist, etc.. Clients who value their privacy and confidentiality when it comes to their mental health records often will look outside of their insurance network for an out-of-network provider who doesn't have to provide psychotherapy records upon an audit from an insurer and who has strict confidentiality laws in place to protect your privacy and clinical records from anyone else.
2) Avoiding a diagnosis in your chart/be in charge of determining the length of their therapy.
Similar to above, when utilizing insurance for your mental health care, therapists are required to provide you with a mental health diagnosis which the insurance company then uses to decide how many sessions you are eligible to have with your therapist. Many clients want to avoid having a mental health diagnosis on their permanent medical records (as this may impact employment opportunities and/or applications for life and disability insurance, etc.) and they like to determine their own length of therapy and not have their therapy be abruptly terminated by their insurer before they feel complete and ready to end therapy.
3) They can't find anyone they click with. I’ve said this before but good therapy will not happen if you don’t feel comfortable and like the therapist you are working with. So some clients find that it’s worth investing in out-of-network therapy because they cannot find a therapist in-network that they just click with, that they really like, and/or who has expertise in the issues they’re wanting to address.
However, if you do want to seek counseling using your out-of-network insurance benefits, here are some tips.
1. Check your out-of-network benefits
These are typically in the Summary of Benefits, included in a member information packet or on your insurance company website. Keep an eye out for these terms: Out-of-network deductible:
This is the amount of money you have to pay before you are eligible for reimbursement.
2. Call your insurance company to verify your benefits
The best way to be absolutely sure of your benefits is to clarify with your insurance company member services line. You can find this phone number on the back of your insurance card. Ask these questions when speaking to your insurance company about benefits:How much of my deductible has been met this year?What is my out-of-network deductible for outpatient mental health?What is my out-of-network coinsurance for outpatient mental health?Do I need a referral from an in-network provider to see someone out-of-network?How do I submit claim forms for reimbursement?
3. Ask your therapist for a Superbill
When you’re looking for a therapist, ask if she or he is willing to submit claims to your insurance company for reimbursement. While some therapists offer this, typically, the client is responsible for submitting claims.Your therapist will provide you a document called a Superbill that you send directly to your insurance company at the end of each month. The Superbill details how many sessions you’ve had, and the total fee.
4. Receive out-of-network reimbursement
You’ll need to pay your therapist the entire session fee at the time of service, but depending on your specific plan, your insurance company will mail you a check to reimburse a portion of that cost. If you have good out-of-network benefits, your insurance company may reimburse you as much as 80% of each session fee, depending on your plan and the therapist’s rate. This means that in some situations, using your out-of-network benefits can actually be more affordable or comparable to your standard copay to see an in-network therapist.