When you see a provider who is out-of-network (OON) with your insurance, it means the provider does not have a contract with your insurance company. This gives you more freedom in choosing your provider, but it also means your insurance will handle costs differently compared to in-network care.
With OON benefits, you usually:
- Pay the provider directly at the time of service.
- Submit superbills to your insurance company for reimbursement*
- Receive reimbursement only after you have met your out-of-network deductible.
*At Edward Jenny & Associates, we also are partnered with Mentaya, which is an optional service that can submit superbills on your behalf for a fee. You can use Mentaya’s benefits checker to learn if you have out of network benefits or learn more about Mentaya.
Understanding your OON Benefits:
OON Deductible: The amount you must pay before your benefits “kick in;” this amount usually must be paid in full before the insurance pays any costs
OON Coverage: This is the cost covered by your insurance once your deductible has been met. It is usually a percentage (i.e., 70%).
Using the cost of the session multiplied by the percentage covered provides a general estimate of how much you will be reimbursed after your deductible is met.
Example: $200 session x 70% coverage = $140 reimbursed per session (after the deductible is met).
The Caveat: Allowable Amounts
What is an allowable amount?
It’s the maximum fee your insurance company has determined they will “allow” for a particular service. This is not necessarily the same as the amount your provider charges.
Example: If your therapist charges $200 per session and your insurance’s allowable amount is $160 per session, your insurance will base both your deductible and any future reimbursement only on that $160. The remaining $40 is considered “non-covered” and is typically your responsibility.
How Allowable Amounts Affect Your Deductible and Reimbursement
Deductible:
Only the allowable amount counts toward your deductible. This can affect how quickly you meet your deductible.
Example: If you have $1600 left of your OON deductible and each session costs $200, you might expect to reach your deductible after 8 sessions (1,600/200=8). However, if the allowable amount is only $160 per session, it would actually take 10 sessions for you to meet your deductible (1,600/160=10)
Reimbursement:
Once your deductible is met, your reimbursement is based on the allowable amount, not the full amount charged. This can affect the amount you get reimbursed for services.
Example: If your plan covers 70% of your OON services and the cost of the session is $200, but the allowable amount is only $160, you would only be reimbursed for 70% of $160 ($112) instead of 70% of $200 ($140).
Finding Out Your Allowable Amount
Unfortunately, insurance companies often will not share allowable amounts with out-of-network providers. That means we usually cannot tell you exactly what your allowable amount is for therapy or psychological assessments in advance. However, there are some resources you can use to get a more accurate estimate.
1)Calling your insurance directly and asking:
-
- “What is the allowable amount for CPT code 90837 (individual therapy)?”
- “What is the allowable amount for CPT code 96130, 96131, 96136, 96137 (psychological testing)?”
2)Using online tools like the Fair Health Consumer Estimate Calculator to get an estimate of allowable amounts based on rates in your area.
Other Things to Know About OON Billing
- Reimbursement Methods: Many insurance companies send reimbursement directly to you either through checks in the mail or through a portal. Providers are generally not able to tell how you’re getting paid. So, make sure you know what method you’re getting reimbursed through, so that you don’t miss a check in the mail or online.
- Timelines: OON claims can take several weeks to process. Keep this in mind when budgeting for care.
DISCLAIMER: Please note that the above information does not apply to emergency out-of-network care or in-network care. Please see the CMS website for information on the No Surprises Act.
