If your provider is in-network it means they signed a contract with your insurance company to accept a certain rate (often discounted rate) and complete paperwork in the format directed by the insurance company. It also means that they have agreed to give the insurance company access to your medical records. If using an in-network provider you are usually only responsible for your co-pay and deductible for services covered by your health plan. Keep in mind services are only covered by health insurance if they are considered medically necessary. If using an in-network provider the insurance company does have access to your medical records to determine medical necessity. Also, insurance companies may only reimburse for a limited number of sessions. Please contact your provider to see what insurance companies they have chosen to contract with.
Out-of-Network providers have not signed a contract with the insurance company. Therefore you are responsible for the entire fee at the time of service and then your insurance company will reimburse you for a portion of the fee. This can save you money over self-pay, but benefits most likely will fall under the same limitations as those with an in-network provider. Clinical information still must be provided to the insurance company for use of out-of-network benefits. Not all insurance plans have out-of-network benefits and not all benefits work the same so it is important to contact your insurance company and verify your benefits.
Self-pay means you choose to not use your insurance benefits to pay for services. Medical records are exempt from insurance reporting and compliance audits. Clinical diagnosis and copies of your medical record will not be accessible to your insurance company and kept confidential under Ohio law. Self-pay allows you to receive psychotherapy for what you feel is important without it being determined as medically necessary. It gives you more control over your privacy, which services you use, what clinician you see and the frequency that you you see them.
One option for out-of-network claims is to use a service like Better. Better can file your out-of-network claim for you and determine your eligibility.
For In-Network services you will need to contact your insurance directly to ask about benefits. If you want to file your own out-of-network claims you will also need to contact your insurance company directly. Insurance plans vary greatly even within a company.
Helpful questions to ask your insurance company:
You may choose to file the claim yourself or use a service like Better. Better is a service that can simplify the process of reimbursement. You can either download the app on your phone or signup online. Out-of-Network reimbursement is as simple as sending them a picture of your insurance card and forwarding them the superbills. Superbills are a Statement of Insurance Reimbursement that your clinician will send you. For all claims that are filed towards the deductible or that are otherwise deemed ineligible for reimbursement, Better is free of charge. Better only charges the 10% service fee for the insurance reimbursements they receive.
You may also choose to file the claim yourself with no service fee. Your clinician will provide you with superbills directly if you would like to send in your own claims. Discuss with your clinician how to do this and they will be able to assist you by providing the proper documentation.
If you have further questions or concerns about payment options discuss them with your clinician. Your health care is your choice and you do have options.