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What if my provider isn’t “in network?”Stephen Hill2017-07-10T22:45:48+00:00
When new clients call me based on my expertise areas, or because they have received a trusted referral, they understandably may have questions if they find out I am out-of-network for their insurance. What exactly will the difference be financially? In the long run where is the best place to invest your money, energy and time?
With the huge number of health plans out there, few psychologists decide to contract “in-network” for every policy available. I originally signed up for some plans and not others based on whether the reimbursement was fair, and whether customer service was actually available if needed. My own physician’s office did the same, and actually had to withdraw from several plans due to ongoing issues with non-payment, despite their diligent follow-up. EAP plans are designed for very simple and short-term problems, and tend to reimburse less than half of a normal insurance rate; so as you can imagine, quality may be limited for EAP plans, and EAP providers typically do not offer depth of experience. Over time, I reluctantly resigned as an in-network provider when reimbursement steadily fell each and every year instead of growing with inflation, and when customer service for providers disappeared in the early 2000s after being excellent at one time. The upside of this decision was to improve how well I can protect your privacy and data security. Once I was independent, insurance companies could no longer insist on seeing your full mental health record for routine tasks, and they could not mandate that I send your sensitive healthcare data electronically, given how common data breaches have become.
Beyond improvements with security and privacy, in talking to potential clients, I like to outline four other points to consider in making a wise healthcare choice:
Most importantly, many clients are confused, or are even misled by their insurance company to believe they will receive no benefits if they choose an out-of-network provider that they trust. Typically, this just isn’t true. Although a few plans truly do not cover out-of-network services, most provide a decent benefit but with different rules applying. For example, when I last researched a number of large local employers with Blue Cross of Idaho “PPO” plans, I found that roughly 80% still provided an out-of-network benefit for mental health services. The difference with seeing an out-of-network provider could be having to meet a different deductible amount, or in receiving a 50% benefit vs. 70% in-network.
Second, whereas families often would understand the importance of early intervention for physical health problems, they may fail to consider the real costs of non-treatment when it comes to mental health. When a child or adult may have broken a bone, most won’t hesitate to go get an x-ray, knowing that delayed treatment could result in further injury, infection or other complications. Mental health often works the same way. When necessary counseling is postponed, in the mean time there can be costs to emotional health, relationships or work performance. Just as with physical health, delaying treatment may result in needing more complex, lengthy and more costly services later on, whereas early intervention might have initially resolved the problems rather quickly and at a lower cost.
Third, except for prescriptions and family doctor visits, most insurance plans require meeting a deductible before benefits begin, regardless of the provider’s network status. So, during the time the deductible is being met, clients often have the freedom to choose any provider they wish at little additional cost. Once the insurance deductible is met, you can always transfer your counseling to an in-network therapist at that point. In the meantime, you can enjoy the freedom of working with your first-choice therapist, gaining valuable tools and ideas you can use for lifetime. Finally, those with a high-deductible plan may realize that, honestly, it won’t make any difference whether their provider is in-network, because their counseling would be completed long before the deductible is ever met.
Finally, while most of us love living in a smaller community like the Treasure Valley, realistically this may make it challenging to find an in-network provider when multiple specialties are needed. For example, you may realize you want expertise in ADHD or divorce issues, but you also need a skilled child or family therapist. Others seek an area of expertise like bipolar depression or severe anxiety, but also think a male therapist specifically would have a better chance getting through to their child. Be sure to ask the providers you’re interviewing not just whether they “work with” your concerns, but what kind of special training or supervised experience they have, and how long they specialized in this. You want to compare apples to apples before choosing a therapist, especially if you are seeking more than one specialty.
I empathize when the difference in insurance benefits between in-network and out-of-network is more significant than above. Those are never easy decisions. Should a client stick to someone in-network or even within the EAP benefit who’s cheaper, even if the provider doesn’t have the particular skills they are looking for? I have seen individual cases where this “hope for the best” approach worked out OK, and at a lower cost. I have also met with many adults, children or families after lengthy therapy either failed to be helpful, or even backfired and made things worse. In the meantime, the client was still making a significant investment of their money, time and emotional energy, but without receiving any appreciable gains from this investment. In the end I respect every client must weigh the potential benefits and costs of any given therapy or testing, and to likewise weigh the costs of possibly delaying treatment. If, after considering, you lean toward acting today to find the right specialist for your needs, I hope you will call and see if I am a good fit for your needs.