“Do you accept insurance?” This is usually one of the first questions prospective patients/parents ask me. It’s an important question, and also made its way to my FAQ page! My short answer to that question is, “No.” The more in-depth answer is, “No, I do not accept insurance and am considered an out-of-network (OON) provider. I require payment at every session and provide a superbill that you can submit to your insurance company for any OON benefits you may be eligible for. I accept cash, check credit/debit cards, and HSA/FSA cards.” Let’s figure out what all of that means.

Many of us pay a decent amount of money each year to have health insurance. This allows us access to providers, where we might only have to pay a copay, and then we have a deductible we need to meet, etc. Although it might look “easier” to find an in-network provider and work with them because they take care of all the insurance “stuff” and you just need to show up, it can have some drawbacks.

Before you proceed, let me be clear… I am not bashing anyone who accepts insurance/any provider that is in-network, or anyone who chooses to use an in-network provider. The decision to accept insurance is both a personal choice and a professional/business decision. The decision to go with a doctor in-network is up to each person and family. You have to do what works best for your needs and your family’s needs.

So, what the heck does all this “superbill and OON stuff” mean anyway and why do so many providers not accept insurance? I cannot speak for other providers. However, I can speak to why I don’t accept insurance and why I most likely never will.

Money. No one likes to talk about it, but we all need it (to some degree) to survive in this world. That’s why it is my first bullet. Let’s rip the bandaid off and get it over with. Did I get into this field to “make money?” No. I went into this field to help people. However, that doesn’t mean I don’t need to earn a living. We aren’t allowed to discuss what insurance companies reimburse. Well, I guess I’m allowed to since I am not paneled, but it would just be hearsay and if I cannot fact-check it, I am not going to say the number. However, I can tell you that if I accepted insurance and was trying to make a living off the reimbursement rates I am hearing about, I would need to drastically increase my caseload. Having too many patients can cause burnout and lead to unproductive sessions. Unproductive sessions can leave both the patient and provider feeling defeated or believing that the session was a waste of time and/or money.
Waitlist. Many in-network providers have a waitlist. If you read the first bullet or money and reimbursement rates, as well as the need to increase one’s caseload to make up for the low reimbursement rates, it makes sense that there is a waitlist. Providers can only see so many patients at a time, which in the therapy world is usually one patient per hour. As one patient terminates and leaves therapy, providers want to make sure that the appointment spot gets filled. I admit I used to also have a waitlist. Then, I got rid of it. In my opinion, in the field of mental health, where there are so many variables that could impact treatment, a waitlist is actually a disservice. If I put you on a waitlist, I cannot guarantee a time frame I will be able to see you nor can I guarantee that when “Mondays at 4pm” opens up, that it will work for you. It’s not as if it’s just one appointment you need to make. It’s a recurring and usually standing appointment weekly, biweekly, etc. How is this helping you? I could just say, I am currently full but here are appropriate referrals for you and you can be seen NOW (or at least sooner than I could see you).
Treatment Length. Some insurance companies dictate how long a person can be in therapy or how many sessions they will cover before the person needs to start paying out of pocket. What happens if your insurance only covers 8 sessions, but by 8 sessions what you came to therapy for has not been resolved? What happens if life gets in the way and the original problem you came to therapy for is now on the back burner because something else happened? THERAPY. IS. NOT. COOKIE. CUTTER! What might take one person 3 months to resolve, might take the next person 1 year. Each person’s experience in therapy is unique and on top of everything else going on in life, people could really do without worrying how many covered sessions they have left- this goes for the patient and the provider.
In-Person vs. Online. Some insurance companies/policies will not cover telehealth at all or not cover it for OON providers. *With COVID-19, many have changed their coverage. However, I remember last year some of my colleagues were scrambling to figure out which insurance and which policies were covering telehealth, what codes to use, how to get reimbursed, etc. It took up A LOT of time and energy. Thankfully, I was already providing online therapy prior to the pandemic. As an OON provider who does not speak to insurance companies, I was also able to notify each of my patients and encourage them to speak to their provider at their convenience. Some did, some didn’t. However, the 100% switch to remote therapy did not impact my ability to see patients.
Time. Think of the last time you had to call your insurance company. I can think of the last time I had to. I spent 2 hours of my evening getting bounced from person to person, and nothing was resolved at the end of those 2 hours. Now times that by 25. That would take up a lot of time each week. Having more free time allows me to have a more open schedule to see patients, as well as time for additional training opportunities that would help facilitate future sessions. Could I hire someone to do all of these phone calls? Yes. However, the more people involved increases the likelihood of miscommunication and human error. It also increases the number of people who have access to your Protected Health Information (PHI).
Confidentiality. Protected Health Information is private and confidential, and it needs to stay that way. By paneling with insurance companies, more people have access to your information, which may include diagnoses, treatment plans, and session notes. Being an OON provider allows me to provide you with the information, and for you to make an informed decision on who you want to access that information.

So, let’s fast forward. You found an OON provider that you are thinking of working with. Now what? I recommend asking your insurance company the following questions:

Do I have OON benefits for mental health coverage?
If so, what are they?
How high is my deductible that I need to reach before reimbursement?
Where am I currently at with my deductible?
What is the estimated reimbursement rate for mental health? *This may vary based on diagnosis and procedural code (see below).
Do you cover remote/online therapy for OON providers?
If so, for how long will this coverage last?
How do I submit the superbills for reimbursement?
What CPT codes do you use? *More on this below

Insurance companies sometimes have different coverage and reimbursement rates depending on diagnoses. Unfortunately, I will not be able to provide a diagnosis until after we meet. It is fraudulent to provide a certain diagnosis just for a certain reimbursement rate. Insurance companies may also ask for a CPT code. CPT stands for “Current Procedural Term.” It’s a form of communication to describe what service was provided. The following codes are some of the more common ones I use, and the ones I encourage you to speak to your insurance company about. I encourage you to ask your OON provider what their most common CPT codes are.

90791 Psychodiagnostic Evaluation (initial intake session)
90834 Psychotherapy (45 minutes)
90837 Psychotherapy (60 minutes)
90853 Group Therapy

Now that you have the information from the insurance company and you are ready to start sessions, what do you need to get reimbursed? There is something called a “superbill,” which is a really fancy word for a receipt. This is different than an invoice or a credit card receipt. The superbill has the CPT code(s) on it, diagnosis codes, and all of the information from the provider so the insurance company can verify that the provider is legitimate. Each insurance company is different in terms of how they want you to fill out the paperwork for reimbursement, so I encourage you to ask them how to go about doing this.

Insurance coverage can be confusing and I hope this helps explain things a little bit better! In my practice, I take a hands-off approach to insurance. I do not speak directly to insurance companies due to the above reasons and all the information an insurance company would need from me is always on the superbill. Most people are pleasantly surprised that once they meet their deductible, the insurance company covers about 70% of the cost of therapy. Again, this varies based on the insurance provider and the policy you have.

If you have questions about using an OON provider, I encourage you to speak to the provider first and obtain their information. Next, spend some time with your insurance company asking the above questions. Have paper and a pen ready to write down all the information they provide you. Then, make sure you know the frequency that the OON provider will give you superbills. My billing system allows me to provide superbills after each session or monthly. I ask each patient what their preference is, but other providers may work differently. Communication is key. Ask the questions and get the answers that help you make the most informed decision.