Fees, Insurance, and Frequently Asked Questions

No. I am out of network with all plans. Insurers call this being a non-participating provider.

The reason is who decides what happens in the room. When an insurer pays, it also sets the terms: how many sessions, at what interval, under which diagnosis, and how soon someone has to justify continuing. Staying out of network keeps those decisions between the two of us, and it means no third party holds a file on your care unless you choose to send them one.

That has a real cost, and it is not the right trade for everybody. If paying the full fee is not workable, seeing an in-network therapist is a sensible choice, and I would rather you start with someone than wait.

It means there is no contract between me and your insurance company. You pay me at the time of the session, and if your plan covers out-of-network care you can ask the plan to pay you back part of what you spent. The money comes back to you, not to me.

Two words do most of the work in any answer your insurer gives you, and neither is obvious:

• Deductible - the amount you have to spend yourself before the plan pays anything. Plans usually keep a separate out-of-network deductible, and it is often higher than the in-network one — so meeting one does not mean you have met the other.

• Coinsurance - once the deductible is met, the plan covers a share of the cost and you cover the rest. The share you cover is your coinsurance, and it is written as a percentage.

Three steps, and you control all three.

You pay for the session. I give you a superbill. You submit the superbill to your insurer, and the insurer pays you back according to your plan.

A superbill is an itemized receipt for out-of-network care. It carries my name and license information, the dates of the sessions, the length and type of service, the fee you paid, and a diagnosis code. That last item is not optional. An insurer will not reimburse anything without one.

A diagnosis. Because the superbill has to carry a diagnosis code, submitting it sends your insurer the same clinical information an in-network claim would have sent.

If you do not submit it, nothing goes to any insurer at all. No claim, no code, no record of your care anywhere outside this practice.

So the honest version of the privacy question is this: paying directly does not guarantee that nothing is disclosed. It puts the decision in your hands. You can weigh getting money back against keeping the record here, you can decide differently for different stretches of the work, and you never have to explain the choice to anyone. In network, that choice does not exist.

Two things worth knowing before you make it. If you are covered on somebody else’s plan, a parent’s, a spouse’s, the explanation of benefits generally goes to the policyholder rather than to you. And if you submit some sessions and not others, your insurer only ever sees the ones you submitted.

Four things, in roughly this order of importance:

• Whether the plan has out-of-network mental health benefits at all - some plans have none, and if yours is one of them nothing else on this list matters. Check this first.

• How much of the out-of-network deductible you have already met - early in a plan year, reimbursement is often zero until the deductible is satisfied.

• The coinsurance percentage after that - the share the plan covers once the deductible is met.

• Whether the percentage applies to the fee you paid or to the plan’s own allowed amount — this is the one that surprises people. Many plans set their own figure for what a session is worth and apply the percentage to that number instead of to the fee. When the allowed amount is lower than the fee, the check is smaller than the percentage suggests.

I do not quote expected reimbursement figures, and I would be careful with anyone who does. The spread between plans is wide enough that an average tells you nothing useful about yours.

Call the member services number on your card and ask:

• Do I have out-of-network coverage for outpatient mental health?

• What is my out-of-network deductible, and how much of it have I met this year?

• What is my copay or coinsurance for out-of-network outpatient mental health, and what will my out-of-pocket cost per session be?

• Is the reimbursement a percentage of what I paid, or a percentage of an allowed amount you set? If it is an allowed amount, what is it for a 50-minute session?

• Is a diagnosis required for reimbursement?

• Who receives the explanation of benefits? Me or the policyholder?

• Do I need prior authorization or a referral?

• Is there a limit on the number of sessions per year?

• How do I submit a superbill, and by when?

Write down the date, the time, and the name of the person you spoke to. It is dull advice and it saves arguments later.