Out of network therapy

Submitted by cobaltcruise t3_z9ssnk in washingtondc

Hi all, my insurance (BCBS) indicated their plan allowance is $103 dollars for psychotherapy (billing code 90834) for out of network providers. (I’d pay the difference if a provider charges over this amount plus 35% of $103)

Using fairhealthconsumer.org for DC and this billing code, the typical provider charges $230 (80th percentile of charges) and the typical plan will pay 70% of out of network charges or $161.

Has anyone been successful in pressing for a higher plan allowance after submitting their out of network psychotherapy costs for reimbursement for folks that have out of network coverage?

Or can anyone share their insurance provider and the plan allowance for behavioral health services for my reference? Thank you!

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angafeabeta t1_iyj623s wrote

My provider (UHC) recently dropped their coverage for out of network for the same billing code from 100% to ~$100 as of last month, so that looks in line with what we're now getting. Our benefits team at my company is trying to fight it. The message we're getting is that the insurance provider is trying to really incentivize people going with in-network therapists. Of course.... there aren't a whole lot of in-network therapists around.

I maxed out my FSA to help reduce the sting a little bit. But it's still not a great solution or situation. Sorry you're dealing with it too.

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MicroStakes t1_iykcx2j wrote

Open enrollment season is soon, right? Maybe use that as leverage?

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cobaltcruise OP t1_iyl86p0 wrote

Yeah, seems to me now most plans are similar… was just trying to gauge if anyone has successfully negotiated increasing the plan allowance for nationwide plans out of network using data like local costs from the fair health website because even BCBS kept claiming it’s a ballpark figure and there are a few websites which encourage appealing for a higher allowance with that data. I’ll give it a shot (or three) soon and report back!

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egp2117 t1_j28dw7z wrote

Did you have any success with this? I just switched from my in network therapist to an out of network one and also switched to the ppo plan because I assumed getting some coverage would be better, even with the increase premium from hmo to ppo. But if they’re only reimbursing $103 it’s actually cheaper to go hmo and fully out of pocket for me. Do you know if that that $103 include the co-pay (as in if there’s a $50 co-pay they’ll reimburse $53) or not? They covered $200 of my in network therapist, so that disparity is insane

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Appeal_Mother t1_iymwywd wrote

Ask what their payment is for an EM visit of similar length (45 mins? Would be 99214 or 99215 I think) for a physical health appointment. If it would be much less maybe you can push them on mental health parity.

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cobaltcruise OP t1_iynbzvq wrote

Thank you very much, that’s a great idea, I’ll try it out!

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Yithar t1_iysdlse wrote

In general, reimbursement for psychologists and psychiatrists by insurance is pretty low, which is why they choose to be OON.

> Using fairhealthconsumer.org for DC and this billing code, the typical provider charges $230 (80th percentile of charges) and the typical plan will pay 70% of out of network charges or $161.

I don't think they'll budge on this because there's an allowed amount, similar to in-network, right? So let's say for a procedure the allowed amount is $1200. The insurance would pay 80% ($960) and you'd pay 20%. They're not going to suddenly cover 90%. It's pretty much the same thing.

For my previous employer insurance, for mental health, it was 90% INN and 80% OON.

You can search for HCPCS codes here (since all private insurance bases their reimbursement on Medicare, so if Medicare pays less, they pay less):
https://www.cms.gov/medicare/physician-fee-schedule/search?Y=0&T=4&HT=0&CT=3&H1=90834&M=5

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