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  • Writer's pictureJason Burtchell, PT, Cred. MDT

What does Out of Network mean, anyway?

Out of Network Benefits FAQ

  1. What are out of network benefits? Healthcare providers will often contract with insurance companies and are then “in-network.” Other healthcare providers may not contract with an insurance company (there are many reasons for this) and provide “out of network” services. Your insurance company may provide “out of network” benefits. This generally means that if you would pay the cost of the service up front, but then can submit to your insurance company for reimbursement for some or all of the cost. The amount of reimbursement varies depending on the plan.

  2. How do I check my Out of Network (OON) Benefits? Your insurance’s website will usually list out of network benefits on their website. Prior to seeing your OON provider, it’s a good idea to call your insurance company to see if your specific policy has OON benefits, and if so check if there are any requirements for reimbursement. For example, your insurance may require you to have a referral from your doctor in order to qualify for reimbursement. Some questions you should ask when you are on the phone:

    1. How much of my deductible has been met this year?

    2. What is my out-of-network deductible for outpatient physical therapy?

    3. What is my out-of-network coinsurance for outpatient physical therapy?

    4. Do I need a referral from an in-network provider to see someone out-of-network?

    5. How do I submit claim forms for reimbursement? (Claims are forms that are sent to your insurance company to receive reimbursement for sessions you paid for out of pocket. We recommend you use Reimbursify, an app that makes this process easier).

  3. How do I get reimbursed? Once any prerequisites are met (i.e. getting a referral from your provider if necessary) you would pay for your physical therapy appointment at the time of service. Your therapist will provide you a superbill which you can then use to submit for reimbursement. You can do this yourself, or utilize a service such as Reimbursify to make this process easier. Your reimbursement amount may depend on your deductible, coinsurance, and cost for the service.

  4. What’s a deductible? What’s coinsurance? Your deductible is the amount of money you need to pay before your insurance will reimburse for services. Your insurance may have a separate deductible for “out of network” providers. For example, if you spent $1,500 on your therapy and your out of network deductible is $1,000 and then your insurance pays for 100% of services, you would need to pay the $1,000 before insurance would cover the remaining $500. Coinsurance is the percentage of the service fee that you, the consumer, is responsible for paying. For example, if your coinsurance responsibility is 30% of the cost of a session, and a session costs $150, you would be responsible for $50. Your insurance also may have a maximum “allowed amount,” which caps the amount of money the insurance will cover per session. For example, if the maximum allowed amount for a session is $100 by the insurance, then with a 30% co-insurance you would be reimbursed a maximum of $70. So if a session cost $150, your insurance would reimburse you $70 and you would be responsible for the remaining $80.

  5. Can I use my Healthcare Savings Account (HSA) or Flexible Spending Account? Yes, regardless of whether or not you are submitting for reimbursement from your insurance provider you can use an HSA or FSA to pay for physical therapy services.

  6. Why would I go to an out of network physical therapist? Many reasons, but here are a few:

    1. The care is about you. Resilience Physical Therapy is an out of network practice because we believe that high quality physical therapy is best delivered with you, the client, being the center focus of the care being delivered. Insurance companies will often limit how many visits are covered, or poorly reimburse for therapy which results in shorter treatment sessions, seeing more than one patient at a time, or both.

    2. You want highly personalized care. We provide one on one sessions that generally last 45+ minutes here at Resilience Physical Therapy. This allows us to focus on you and the issue you’re working to recover from. If your therapist is dividing their attention among 1-2 other clients at the same time, how focused are they on your issue? Or if you have a 25 minute session with a therapist instead of 45+ minutes, did you get the same amount of care or time (hint: no).

    3. You have a high deductible plan. These are becoming more common. If you have a deductible of $6,000 and are unlikely to meet your deductible over the course of the year, an out of network can be a cost effective way to access high quality care.

    4. You have good Out of Network Benefits. If you have good out-of-network benefits, your insurance company may reimburse you as much as 80% of each session fee, depending on your plan and the therapist’s rate.This means that in some situations, using your out-of-network benefits can actually be more affordable or comparable to your standard copay to see an in-network therapist.

    5. Privacy. If you would prefer not to disclose your health information to your insurance company (which would be required for in-network or reimbursement for out of network), you can choose to pay privately for services.

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