What is "Out of Network" billing anyway?

What is Out of Network billing anyway?!

This is a question I get all the time, so I thought- let's put it down in one spot!

This only applies if you have health insurance, if you do not, then feel free to skip this post.

When we typically think of using our insurance- we picture using "In Network" benefits:

I have a cold, so I go to the doctor. The doctor charges me $100 (for easy math, we know it's way more than that!). My "copay" is $30. I pay $30. My insurance company fills in the $70.

Many insurance plans also offer "Out of Network" benefits. This is how those generally work:

I'm sick again, this time it's a bit more complicated. My cold is lingering and I'm also noticing heart palpitations. Something feels "off" but I'm not quite sure what. I want to go see a specialist this time, because the general care I received before didn't quite cut it.

I find a specialist in my area who specializes in lingering colds with heart palpitations and general feelings of "off". Omg yay- sign me up! Ok, they're out of network... what does this mean?

Let's pretend my insurance company has a 70/30 split with "Out of Network (OON)" billing.

I go see this specialist and she charges me $150. I pay the $150 upfront, my insurance company reimburses me 30% (in this case $45. Bringing my cost down to $105 total).

But wait! I have an OON deductible. That means as soon as I pay $750 out of pocket, my insurance company kicks in more. Turns out my lingering cold with heart palpitations requires a long term solution. So I'm going to be seeing this specialist for at least 6 months.

Good news is that once I hit the $750 deductible (about 7 sessions of paying $105/session), then my insurance kicks in at 50/50!

Now I'm paying $75/session for my best-fit specialist. She helps me figure out what's going on, provides personalized care, and I heal- yay! I no longer have a cold, my heart palpitations are nonexistent, and my energy is back.

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This is a very simplified version of how OON billing works, but hopefully it helps explain it. The best way to find out what your OON benefits are, is to call your insurance company and ask. Mentaya (www.mentaya.com) or Thrizer (www.thrizer.com) will also check your benefits for free!

For many people, the standard providers will work and they'll see results. But some of us need our healthcare to be tailored to us.

I've spent over a decade receiving additional training on how to help survivors of trauma (especially survivors of sexual assault), perfectionists, people-pleasers, and sex workers heal. Each client is individual with their own needs and goals; no cookie-cutter, worksheet-giving therapy here!

If you're ready to work with a specialist, reach out to me today.

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