Out-of-network benefits can give you the confidence to charge your full rate without the guilt of needing to accept insurance to remain accessible.
By Sanjana Sathya, Co-founder at Thrizer
I still remember the first time I heard of “out-of-network benefits.”
I had really found my fit with an out-of-network therapist, but therapy was becoming difficult to sustain every week. After every session, I felt the need to justify whether it was “worth it” for yet another $150 to leave my bank account.
That’s when I talked to a friend about out-of-network benefits.
I was thrilled and confused at the same time. How could I receive money back from insurance if my therapist didn’t accept insurance?
Fast forward 5 years, and that’s what we help thousands of clients do at Thrizer. We help more clients and therapists have this “aha” moment and use their out-of-network benefits to access therapy.
But first, what are out-of-network benefits?
Out-of-network (OON) benefits are coverage on a client’s insurance plan for healthcare services.
When it comes to mental health, OON benefits help clients see the therapist they want despite that therapist not being in-network with their insurer. And best of all, get partially reimbursed for it.
In simpler terms: even if the therapist doesn’t accept insurance directly, the client may have out-of-network benefits in their insurance plan that still allow them to receive some money back on therapy.
Out-of-network benefits for therapy reimburse on average 70% of the session cost, allowing the client to recoup a large portion of the therapist’s fee, all while therapists earn their full rate.
Why is this good news for you as a therapist?
All too often, therapists bear the responsibility of making therapy more accessible at the expense of their well-being.
While accepting insurance is one way to make your services more accessible to clients, it may not be the best choice for all therapists.
As you may know, being paneled with an insurer forces you to deal with a world of challenges:
- Low reimbursement rates
- Heavy administrative burden
- Clawbacks, audits, and notes
But if you’re like the therapists we serve, all you want to focus on is providing quality care to the clients who rely on you.
So, what’s the good news?
Out-of-network coverage can cover 50% or more of your session fees, sometimes even covering all of the cost depending on the client’s insurance plan.
How do out-of-network (OON) benefits work?
If you’re a bit rusty on how OON benefits work (very understandable), read this section for a gentle reminder. And if you’re well-versed on OON benefits already, feel free to skip to the example below. In an upcoming section, we’ll talk about attracting private pay clients with OON benefits.
The primary difference between out-of-network vs. in-network therapy is that clients have to submit claims to insurance themselves.
This means that clients will generally pay your full fee upfront, submit an insurance claim, and wait for reimbursement to recover a portion of the cost.
A therapist needs to provide the client with a superbill, which as you know is a document that summarizes the sessions they’ve had along with other information. That includes a diagnosis, CPT code, and your provider NPI.
Your client can submit this superbill to their insurance and once approved, receive a reimbursement check for a portion of the cost. Reimbursement waiting periods vary by plan but can take on average 4-6 weeks.
Many EHRs can automatically generate superbills for clients. They’re typically provided monthly or more frequently if the client desires.
How are reimbursement rates calculated?
Client reimbursement rates vary by insurance plan. They can often feel like a black box. Below, we will break it all down for you.
The breakdown of their insurance benefits will include several different terms that are important for you to know to truly understand your client’s out-of-pocket cost for therapy. These are the key terms to know ⬇️
Allowed amount: The allowed rate is the maximum amount that a client’s insurance will accept and reimburse for therapy. This does not dictate how much you as a clinician can charge, just the maximum that insurance is willing to cover for each session.
Deductible: This is the amount the client must pay out-of-pocket before they start receiving out-of-network reimbursements. It’s the first stepping stone in using insurance benefits. Clients pay your full rate for sessions (out of pocket) till this deductible is met. Only the allowed amount can be applied toward the deductible for each session. For example, if the allowed amount is $150 but your session fee is $200, each session would chip away $150 from the deductible, not the full $200.
Co-insurance: The percentage of the allowed amount that the client might be responsible for after they’ve met their deductible.
Reimbursement amount: The amount the client will receive towards each session after they meet their deductible. It is determined by their allowed amount and co-insurance. We’ll cover the calculation in the example below.
Let’s run through a real-world example
Say you charge $200/session.
Your client’s out-of-network benefits have the following breakdown:
- Deductible: $750
- Allowed amount: $150/session
- Co-insurance: 30%
This means that your client would pay your full rate of $200/session for the first 5 sessions to meet their deductible ($150 allowed amount x 5 sessions = $750 deductible).
After that, the client is responsible for 30% of the $150 allowed amount, which means insurance would cover the remaining 70% of the $150 allowed amount in reimbursement = $105/session.
Therefore, the client would be responsible for the difference between your rate and the reimbursement amount, i.e. $200 – $105 = $95/session.
In other words, the client went from paying $200/session to $95/session using their out-of-network benefits!
Can you already start to see how helping clients with their OON benefits can help keep your practice full and clients happy?
Options for incorporating out of network benefits into your practice
Now, we’re pretty gung-ho about out of network benefits and how they can unleash the potential of your practice.
But not everyone is ready to go 100% private pay. So what’s one to do?
Accepting some insurances
One option is to continue to accept certain insurances, while simultaneously seeing clients who may have out-of-network benefits for insurances you don’t accept.
This allows you to tap into a broader set of clients beyond the insurances you are paneled with while still ensuring those clients have a way to save on their sessions.
The best part? This can help eliminate the burden of needing to panel with numerous insurances just to meet your desired caseload.
More insurance always means more paperwork and less time spent on meaningful work.
Going fully private pay
Alternatively, out-of-network benefits also give therapists the confidence to go fully private pay and not have to deal with insurance.
All the time you previously spent on dealing with insurance can now be spent on care (including some much-needed self-care).
Insurances are much more lenient when it comes to out-of-network claims – that means no need to submit notes, deal with clawbacks, or follow up incessantly for reimbursements.
Ultimately, it provides you as a therapist the freedom to
- Charge what you deserve
- Set a much more manageable caseload
- Create stronger therapeutic relationships
- Get back time normally spent on insurance hassles and admin tasks
What’s not to love?
How OON benefits help you attract private pay clients
Now for the good part.
If you’ve read this far, you’re ready to attract private pay clients by offering support with their OON benefits.
Start incorporating the conversation around OON benefits on your website, Psychology Today, and intake calls.
Here’s how simple it can be:
When a new potential client contacts you and says they need to use their insurance, let them know they have another option.
Instead of telling them that you don’t accept insurance (or at least not their insurance), you can ask about their out-of-network benefits.
And better yet, you can instantly let them know if they have out-of-network benefits and what their reduced out-of-pocket cost would be using Thrizer’s free benefits calculator.
Perhaps $200 would be too much for them, but letting them know they only have to pay $80 for each session post-deductible could help you convert them into a future client.
How might offering help with clients OON benefits transform your practice?
Instead of having to refer out people who contact you, you can save the day for them. Most people don’t know they have out of network benefits!
So teaching them about their benefits instantly makes them grateful – who doesn’t love saving 50% on therapy?
But what if insurance does all my marketing?
Getting off insurance is admittedly hard if we’re reliant on their panel for referrals.
To put it simply, you’ll have to develop some marketing chops.
Luckily, that’s what Greg is so excellent at. With his help, you can have your marketing set up and dialed in within 6 months so that leaving insurance seems like a much easier option.
If referrals from insurance panels keep your practice afloat, make it a goal to become independent and fill your practice with your ideal clients.
You can do it!
Are there any challenges with superbills?
It’s important to be clear-eyed with insurers. After all, their incentive is to make things difficult for plan members. The less they reimburse, the more they keep for themselves.
While clients can benefit greatly from out-of-network benefits and superbills, there may be a few pitfalls they can fall into:
Lack of transparency: As we said above, most people don’t realize they have out of network benefits. And the ones who do don’t know how much they’ll get back. “You could get some money back” vs “You could get back $90 per session” present very different narratives for therapy clients.
Manually submitting superbills: People are often in therapy when parts of their lives become unmanageable. So adding “submit my superbills after every session” to their to-do list is a nonstarter. This is one reason why automating superbill submission for the client can be incredibly helpful.
Insurance follow-ups: Insurers often deny claims with minimal explanation. Following up on claims takes time from clients who are already overburdened.
Long reimbursement waits: A privileged few can pay for therapy and afford to wait 4-6 weeks for partial reimbursement. Even with out of network benefits where half a client’s session is covered, waiting for reimbursement is a large deterrent.
We believe out of network benefits are still the key to accessibility for so many. It’s important to be aware of the pitfalls and to avoid them. Don’t let them deter people away from getting support!
What is Thrizer and how can it help fill my practice?
Thrizer is a platform that manages out-of-network billing for therapists and clients.
We operate as a payment platform that you would use to charge your clients for sessions, similar to Stripe or Square.
The benefit of charging through Thrizer though is that every time you charge a client, an out-of-network claim is automatically submitted to insurance (no more superbills!). You can then offload all the insurance stress onto us. You can even use our instant benefits calculator to let your clients know what they would owe for your sessions with out-of-network benefits, all before their first session.
The best part? Once a client meets their deductible, they can choose to just pay a copay for sessions to skip the reimbursement wait. Thrizer covers the rest of your rate to make you whole upfront and then waits for reimbursement on the client’s behalf.
This is not too good to be true. Hundreds of therapists are already using Thrizer and love that they can save time and provide more accessibility and care for clients. Plus, there are additional benefits that some have experienced such as growing their practice many times over.
We’ll support your clients in using their out-of-network benefits, so they get the reimbursements they need to continue accessing therapy, on time and without stress. Watch our demo today and sign up for free.
