What are Out-of-Network Benefits?
Union Square Practice is a private practice. We do not accept insurance, however we do help to provide documentation for out of network benefits. Many people do not realize that they have out-of-network benefits that can reimburse them for services! Out-of-network benefits are what your insurance uses should you decide to see a clinician who does not accept your insurance. Not everyone has out-of-network benefits, though many insurance plans do offer them. Generally, these benefits will become effective after you have met your insurance deductible. Once that deductible is met, out-of-network insurance typically reimburses anywhere from 50-80% of the cost per service. The exact amount reimbursed is specific to your insurance provider and to what your insurance provider deems as the typical cost of services you are seeking.
How can I learn what my specific out-of-network benefits are and exact reimbursements?
You will need to call your insurance provider to understand your out-of-network benefits. We’ve outlined some steps below:
- Call your insurance provider using the number on the back of your insurance card.
- Let your insurance provider know you’d like to understand what your out-of-network benefits are.
- Your insurance will also most likely ask for codes that these services would be billed under which we outline below.
- The insurance company will also need to know the zip code for services. Union Square Practice is in zip code 10001.
Here are some good questions to ask your provider:
- What rate am I reimbursed for behavioral health services?
- Do I need to meet a deductible before I am reimbursed? How much is that deductible?
- Is there any limitation to the number of sessions that can be reimbursed?
Below are the most commonly used codes and an outline of when they are used depending on the service
For providers that prescribe medication (Psychiatrists and Psychiatric Nurse Practitioners):
90792 – 90-minute initial session
99213 + 90836 – 45-minute follow up sessions (includes therapy and medication management)
99213 + 90833 – 30-minute follow up sessions (medication management only)
Billing Codes for talk therapy (Psychologists, Mental Health Counselors, and Social Workers):
90791 – Initial consultation
90834 – 45-minute follow up sessions
Billing Codes for TMS (Transcranial Magnetic Stimulation)
90867 – Tcranial magn stim tx plan
90868 – Tcranial magn stim tx deli
Are there any benefits to using out of network insurance?
Yes! Most therapy practices in New York are out-of-network. Utilizing out-of-network benefits grants you a much larger range of clinicians to select from. This can be helpful when looking for someone that has a specific specialization or approach. Additionally, out-of-pocket costs can help you reach your deductible (this applies to medical benefits as well!) requirement sooner. You can also use your FSA card to pay for these costs!
Are there any benefits to paying the entire cost out of pocket?
We understand that paying out of pocket may not be feasible for everyone. However, paying out of pocket puts you in complete control of your care. This removes any limitations applied by insurance, such as duration and frequency of therapy, and allows individuals to choose the clinician who is the best fit.
Is there a way to estimate how much I might be reimbursed?
Yes! Below is an example. Please note this is not an exact estimate.
Example: You are looking to engage in weekly therapy sessions and are told the cost of each session would be $250. Assuming the reimbursement of out-of-network benefits is 60%, you can multiply $250 by 60% and learn that reimbursement is $150. By subtracting the reimbursement from the initial fee ($250-$150), you can calculate your out-of-pocket expense, which is $100.
Note: Effective January 1, 2022, the No Surprises Act requires medical practitioners to provide good faith estimates of services before services are rendered. The fee range provided to you in an email or screening call will be reasonably accurate to what you can expect to pay per session as a patient.