What is an out-of-network provider?
An out-of-network provider is any healthcare professional who does not have a contract with insurance companies (some providers select which companies they work with, and some do not work with any at all.)
To understand this, it also helps to understand how healthcare providers receive payment from insurance companies:
Patient gets a service from a healthcare provider who collects their insurance information
The provider submits billing codes for the services performed to the insurance company
Insurance company decides if they think the service was needed (key point here, the provider and the patient are not deciding what they think is best, someone who doesn’t know you at all is making this decision!)
Insurance company pays the provider for the service, usually weeks-months after the service was provided
Also, most providers employ billers and coders to do this since this process takes a significant amount of time. And now the provider needs to see more patients to pay for these staff members, so they spend less time with their patients (ever been to the doctor and you only get 10 min?)
An out-of-network provider uses a different model:
Patient gets a service from a healthcare provider and collects payment from the patient (this example is specifically for a patient paying privately, but we also accept HSA, FSA, and ESA funds for payment!)
If the patient wants insurance reimbursement, they request a superbill from the provider
Patient submits the superbill to their insurance company and gets reimbursed based on their plan’s policy for out-of-network services (we talk about this more below!)
We all have health insurance, so why might it be beneficial for you to go out-of-network for healthcare?
Having worked in an insurance based therapy clinic for 7 1/2 years, I found a lot of frustrations when it came to working with insurance companies. Additionally, in my personal life there are so many times when I have found the insurance system misleading, unhelpful, and have ended up paying way more then I thought I would have to for services! One of the reasons we opened Bloom was to offer a choice to families in Southern AZ so that they can choose what model of care is best for them. Here are some of the benefits you might find working with an out-of-network provider:
Ability to chose your own provider based on specialized skills and personality rather then being limited to a short list of providers on the insurance company’s website
Avoiding delays in care while waiting on referrals and preauthorizations
Avoiding long wait lists to get seen at insurance based clinics
Ability to work with your therapist to set the goals and treatment plan that is best for your unique child (not based on reimbursement rates or visit limits)
Longer treatment sessions, and your therapist is fully present during sessions because they are not trying to see a crazy number of patients everyday
Access to your therapist between sessions if a question comes up
Avoiding breaks in services when paperwork or insurance authorization needs to be renewed (which always seems to happen right when your child is making progress!)
Ability to work with your therapist at an increased frequency or participate in a therapy intensive to accelerate progress and maximize your child’s outcomes!
How can I find out if my insurance will play for out-of-network services?
Many insurance companies cover 50-80% for out-of-network services. This is why you often hear me using the term out-of-network provider vs cash-pay provider, because while I do not hold contracts with most insurance companies but this doesn’t mean your insurance won’t pay for our services! Each insurance plan is different, and reimbursement can be influenced by the type of service, deductibles, etc. The best way to know is to call your insurance company directly, and we even have a worksheet so you know exactly what questions to ask! (Click here for the worksheet.) If you find that you are wanting more choices in your healthcare, I also recommend looking at out-of-network coverage when you select your insurance plan each year. I want every family to feel empowered to ask questions and understand their benefits, both in-network and out-of-network, so they can make the best choice for their care.
Can going out-of-network ever save me money?
There are definitely situations when going out-of-network results in savings for you, directly or indirectly, even if you don’t get any reimbursement from your insurance. I can think of many scenarios, but here is a real world example I have encountered in Southern AZ:
A 1 month old needs PT. It takes 2 weeks to get a referral sent, 2 more weeks to get pre-authorization, and there is a 2 month waitlist for the eval. Baby has their PT eval at 4 months, but while waiting the concerns have gotten worse and they need PT once per week for 4 months. Lets assume they only pay a co-pay of $50 per visit and the rest is covered 100%. Total cost is $850, plus time and transportation to the clinic.
A 1 month old needs PT. The parents call an out-of-network provider and baby is seen for a PT eval the next week. Since baby is young and the problem just started, they only need 3 treatment sessions over 2 months. Total cost is $650.
Another example of cost savings:
A family lives 1.5 hours from the nearest pediatric clinic, and attends therapy once per week year round. The therapy is covered 100% but they pay gas, and time to travel 3 hours each week. Instead, they decide to attend a 2 week intensive, twice per year and stay locally with a friend or at the Ronald McDonald House. They pay out of pocket an estimated $4,000 but save on the gas and have more time at home with their family each week while their child makes the same amount of progress!
I hope this post was able to show you some of the value provided by out-of-network providers and how having this choice allows families to seek the best possible care for their child! If you ever have questions about how our services could help you, give us a call!