Decoding Out-Of-Network Insurance Benefits

As I find myself late in my third trimester of pregnancy, needing many more healthcare services than I typically would, I realize that so many of my healthcare providers are out-of-network with my health insurance.

Chiropractor? Out-of-network. Acupuncturist? Out-of-network. Lactation Consultant? Out-of-network. My amazing pre- and post-partum physical therapist who currently works for a practice that’s in-network with my insurance? She’s starting her own practice at the end of the month and will no longer be in-network with any insurance. Sigh……

Why are so many providers choosing to be out-of-network with health insurance?

The short answer is they can. They have mastered their crafts, built up a following and no longer have to accept the ever-decreasing reimbursement rates that insurance companies offer.

Because reimbursement rates continue to plummet, in-network providers are often pressed to see as many patients as possible in a workday. I know an orthopedic surgeon who sees between 35–40 patients in one day, typically spending less than 5 minutes with each one. When I ask the patients how their visit went with this doctor, they remark on how quick the visit was and how they left a bit confused after trying to digest important, sometimes complicated medical information so quickly.

I’ve also heard countless stories from patients who’ve “tried physical therapy before” at a large corporate PT clinic, who describe the therapist treating 4 patients at the same time and running back and forth between them all. Have you had an experience like this? These models seem doomed for both positive patient outcomes and healthcare providers' sanity and mental health.

The other key piece to healthcare providers going out-of-network is the geographic location and, more specifically, the amount of disposable income in that particular geographic location. Salaries are higher in metropolitan areas. Employers tend to offer better health insurance policies that include out-of-network benefits in these regions.

Therefore, many healthcare providers will choose to go out-of-network in metropolitan areas like Washington, DC, where we are located. Providers are able to do this because their potential patients have either the extra means or the excellent healthcare coverage to be able to see them.

As I think about what this means for me in my current situation, it gives me insight into what our potential patients at SchrothDC are up against; gathering information about costs, figuring out the logistics of filing a claim on your own, and deciding whether it’s in your budget to see an out-of-network provider.

In my case, the positive experiences I’ve had in the past with my entire prenatal team – lactation consultant, physical therapist, acupuncturist, and chiropractor – are the reason I will see them again this time around; paying out of pocket at the time of service, filing claims on my own behalf, and maybe eventually getting my health insurance to cover these services once I’ve met my out-of-network deductible (more on that later).

I’ve always felt seen, heard, well taken care of, never rushed, and empowered by these practitioners. They are worth the extra money and the extra work!

So, where to begin?

If this is new territory for you, as it is for me, the first step is finding out if you have out-of-network health insurance benefits through your plan. Most policies (other than HMO’s and catastrophic plans) offer some out-of-network coverage, but it can vary drastically from plan to plan. 

A phone call to the number on the back of your insurance card works, as does a search of your health insurance’s website or portal.

The most important questions to get answered are:

  • Do I have any out-of-network [i.e. physical therapy] benefits?

  • Do I have an out-of-network deductible that must be met?

  • Do I have a copay or coinsurance after the deductible is met?

  • Is there a visit limit?

  • Is a pre-authorization required?

  • How do I submit claims if the provider does not submit claims on my behalf?

I’ll use myself and my current health insurance plan as an example to try to make sense of this all. If I want to continue with my lovely pre- and post-natal physical therapist once she transitions to out-of-network status, this is what I can expect to pay. 

Deductibles

I have a $2000 out-of-network deductible. (This is likely mid-range. I’ve seen $150 deductibles and $5000 deductibles.) This means the first $2000 I spend out of network will come out of my pocket, with no reimbursement from my health insurance company.

My physical therapist charges $200 per session, which makes the math really easy. My first 10 sessions with her will come out of my pocket, at which point I will reach my out-of-network deductible.

Sidenote: I will also be submitting my out-of-network claims from my lactation consultant, acupuncturist, and chiropractor, and all of their fees that I pay will count toward my out-of-network deductible, which means I can hopefully reach it sooner. 

For simplicity of this blog post, I will use the example of my physical therapist as my sole out-of-network provider.

Copays/Coinsurance

Ok, so I’ve finally reached my out-of-network deductible. Now what happens?

I will have a $50 copay per visit after my 10th PT visit. This is different in every plan. Yours might be $30. Alternatively, instead of a copay, you may have what’s called a “coinsurance”. This is typically a percentage: if your coinsurance is 15%, you can expect your insurance company to pay for the remaining 85% of the charges of the out-of-network provider.

Visit Limits

There are sometimes limits on how many visits of PT you can have per year. Mine is 30 visits/year, even out-of-network. Mine is also combined with Occupational Therapy (OT), meaning I have 30 visits of PT and OT combined for the year.

Pre-Authorizations

My particular plan does not require this, but some do. Tricare Prime, for example, requires a pre-authorization in order to obtain insurance coverage for out-of-network services. A pre-authorization is basically paperwork indicating the desired service is medically necessary, along with reasoning as to why the patient needs to go out of network. 

In the case of Schroth Physical Therapy, there are no in-network therapists in the Washington DC, area. This allows the patient to go out-of-network.

Submitting your own claims

This task is not as daunting as I had originally thought, thank goodness. There are a couple of options for doing this. 

  1. One is an app called Reimbursify, whose pitch is literally to “simplify out-of-network care for practitioners and patients.” I downloaded it this week, and my first claim submission was free. 

    After the 1st submission, you can expect to pay either $3.99 per claim if paying one by one, or you can purchase a “10-pack” for $29.99, bringing the cost down to $2.99 per claim. Think of Reimbursify as a clearinghouse for claims. Reimbursement will come directly from your insurance company; Reimbursify does not get a cut.

  2. The other option for submitting claims is directly to your insurance company. Every insurance company is different: some want them snail mailed or faxed, or best case scenario, there’s an online platform to upload your out-of-network claims to directly.

    I discovered that my health insurance, CareFirst, a Blue Cross Blue Shield Company, has this capability – hooray! This makes it as simple as Reimbursify does.

What information will you need to submit your own claims?

  • A receipt from your out-of-network provider. Also called a “Superbill”

  • The provider’s name

  • The provider’s office address

  • The Provider’s NPI (National Provider Identifier) number

  • The Provider’s Tax ID Number (Also called an EIN)

  • The date of service of your treatment

  • The ICD-10 (Diagnosis Code(s))

  • The CPT code(s), number of units for each CPT code, and the price for each CPT code

Don’t let this laundry list overwhelm you – all of the above information should be listed on the provider’s Superbill. If you can’t find something, ask your provider for help. Speaking as an out-of-network clinician, we want you to have the best chance of getting reimbursed!

I’ve decided to experiment to see which claims submission process is quicker and/or more efficient. I’ve submitted one of my out-of-network claims on Reimbursify and another on my CareFirst platform.

If the CareFirst platform is as simple and speedy as Reimbursify, I can save myself the $3-4 per claim fee that Reimbursify charges. Processing claims takes about 30 days, so I will update this post once I have an answer for you all.

As we wrap this up, a few considerations….

Try not to be immediately overwhelmed when finding out a provider is out-of-network. Although new to you, you may have fantastic out-of-network coverage you haven’t tapped into before. 

This was the case with my mother, who had an amazing Anthem BCBS policy with top-notch out-of-network benefits, but she never knew until she desperately needed a new endocrinologist, saw someone who was highly recommended to her who happened to be out-of-network, and she was reimbursed handsomely for each visit (not to mention finally got appropriate endocrinologic care).

Another tip: prioritize quality care. Spending money on good healthcare can have large future returns. Given the choice between 50 sessions of crummy pre- and post-natal physical therapy at $30 copay/session versus 10 sessions of high-quality out-of-network PT at $200/session is a no-brainer for me.

If you have any lingering questions about how out-of-network providers work, please, connect with us. We’re always happy to take calls, respond to emails, or chat in person if you’re at National Scoliosis Center in Fairfax, VA.

We wish you all good health & good healthcare.

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