What Out-of-Network Psychiatry Really Costs

You have found a psychiatrist you want to work with, and then you find out they are out-of-network. The next question is always the same one: what is this actually going to cost me? It is a fair question, and a harder one to answer than it looks, because the amount you pay at the time of the visit and the amount you are finally out of pocket are usually two different numbers. Here is how the arithmetic works, so you can estimate your own situation before you commit to anything.

Current fees are listed on the insurance and payment page. This article is about the mechanics around them.

The amount you are quoted is not usually the amount you keep paying

If your insurance plan includes out-of-network benefits, some portion of what you pay is designed to come back to you afterwards. You pay the practice in full, and your insurer reimburses you separately. That is the whole model, and it is why an out-of-network fee and an out-of-network cost are not the same thing.

There is one condition, and it matters more than anything else on this page: your plan has to have out-of-network benefits in the first place. Mind Body Seven is out-of-network with every insurer, and that includes Medicare, Medicaid and Medicaid Managed Care plans. If your plan only covers in-network providers, it will not cover visits here at all, and nothing below applies to you. Check that first, before you work out any numbers.

Your deductible comes first

Until you have met your deductible, you pay the full cost of your sessions and your insurer contributes nothing. The deductible amount varies by plan, sometimes by a lot.

The detail people miss is that many plans carry a separate out-of-network deductible, distinct from the in-network one, and often considerably higher. Having met your in-network deductible for the year does not necessarily mean you have met the out-of-network one. When you call your insurer, ask about the out-of-network deductible specifically, and ask how much of it you have already met this year.

Reimbursement is a percentage of a number you did not choose

Once your deductible is met, your insurer starts reimbursing a percentage of each visit. That percentage is commonly somewhere between 50% and 80%, though it varies by plan.

Here is the part that surprises people. That percentage is not applied to what you were charged. It is applied to what your insurer considers the approved visit cost, sometimes called the customary or allowed amount. Your insurer sets that figure itself, and it may be lower, occasionally much lower, than the fee you actually paid. The difference between the fee and the approved amount is yours to keep paying, and it does not count toward anything.

This is why two people with the same reimbursement percentage can end up with very different bills. When you call your plan, do not stop at the percentage. Ask what the approved visit cost is for the specific service codes involved.

A worked example

Round numbers, chosen only to show the shape of the arithmetic. These are not this practice’s fees, which are published on the insurance and payment page.

Say a session is billed at $400, your plan’s approved amount for that service is $250, and your plan reimburses 70% of the approved amount once your deductible is met.

• Before the deductible is met, you pay $400 and receive nothing back. Each visit does, however, count toward the deductible.
• After the deductible is met, you still pay $400 on the day. Your insurer then reimburses 70% of $250, which is $175. Your real cost for that visit is $225.

Two things follow. Your cost per visit drops partway through the year rather than staying flat, and the gap between the fee and the approved amount is the number that actually determines affordability. Run the same calculation with your own plan’s figures and you will have a realistic annual estimate rather than a guess.

What is not included in the visit fee

Visit fees cover the visit. Laboratory testing and supplements are billed separately, because what they cost depends entirely on which tests and which products are involved. Dr. Lewis goes through the anticipated cost before ordering anything, so you can decide about lab testing and supplements with the numbers in front of you rather than after the fact.

Worth knowing in advance: insurers treat functional and specialty testing differently from routine bloodwork, and coverage for it is far less predictable. Ask about specific tests rather than assuming testing is covered as a category.

HSA and FSA accounts, and Good Faith Estimates

Many patients pay for psychiatric care using a health savings account or a flexible spending account. Eligibility rules vary between plans and change from year to year, so confirm what yours covers with your plan administrator before you rely on it.

You can also ask the office for a Good Faith Estimate of expected costs before starting care, which is supported by federal healthcare transparency rules. It gives you a written picture of anticipated fees up front. The frequently asked questions page covers this along with payment options and several other billing questions.

What to do before your first visit

Fifteen minutes on the phone with your insurer will tell you more than any article can. Call the number on the back of your card and ask:

• Do I have out-of-network benefits for mental health services?
• Do I have a separate out-of-network deductible, and how much of it have I met?
• What is the reimbursement rate for out-of-network mental health services?
• What is the approved visit cost for those services?

Write the answers down. With those four figures you can calculate your real cost per visit in about a minute.

Then ask the office two things: for a Good Faith Estimate, and how claims and documentation are handled for your particular plan, since that differs between insurers. You can raise both on a free discovery call, along with anything else that is unclear.

If it turns out your plan has no out-of-network benefits at all, say so on that call. There may still be a route that works for you, and it is a better conversation to have before you have ruled anything out.