top of page

Why Choose an "Out of Network" Provider Instead of Using Insurance

Updated: Mar 15, 2023

Choosing to begin therapy can lead to many questions, especially regarding the decision to use your insurance benefits versus paying out of pocket. If you have insurance, it might feel like the natural choice to find a therapist that accepts your insurance. It’s important to learn about the rules and restrictions that come with using an insurance provider, as well as some of the benefits of going outside of your insurance company for mental health care. Why choose to pay out of pocket for therapy?


More Individualized Treatment


Insurance companies often limit the number, frequency, and length of sessions, as well as the type of sessions and therapeutic modalities that are allowed for reimbursement. An in-network therapist has less freedom in curating your treatment to your specific needs due to the limitations placed on them by the insurance company. A client’s insurance company could decline authorization of additional sessions because the treatment may not be seen as progressing fast enough or because the treatment approach isn't recognized by the insurance company. Furthermore, insurance companies may decline to reimburse for any number of reasons, leaving you with a surprise balance. Without these risks and limitations, clients can work with their therapist to determine the best therapeutic approach to help meet their goals.


At Heart Space Counseling Center, we promise to tailor your treatment to your needs, based on your own personal goals, preferences, and what is best for you!


Privacy


Most insurance companies require some level of information about your care in order to provide payment for therapy. This information includes your diagnosis and a description of what takes place in your therapy sessions. When insurance is used for therapy expenses, the therapist is required to provide documentation of these details in order to be reimbursed. If given, the diagnosis becomes a part of your permanent medical record.


At Heart Space, your information is kept private and confidential as long as you are not at risk of harming yourself or someone. The only time your information from your records is released is with signed documentation from you saying what you're desiring to share and with whom. We are happy to provide protected health information when you need us to consult with other providers, legal professionals, or school personnel per your request and to help you when it is needed. Otherwise, your information is kept between you and your therapist.


Ethical Implications for Professionals

As stated above, your therapist is required to provide information including a diagnosis to your insurance company. You are only eligible to use your benefits if you have a diagnosis that insurance companies are willing to cover. Many individuals are interested in counseling for personal growth and exploration, self-improvement, and life transitions; unfortunately, insurance companies may not view these as "medically necessary" and do not consider them valid reasons for compensation. Without a diagnosis, insurance companies may not continue to authorize future sessions. Unfortunately, this puts providers in a dilemma to support certain diagnoses in their documentation in order to get paid; this can lead to unethical or inaccurate diagnosing to find a billable problem.


We at Heart Space believe strongly in personal and professional integrity, upholding our ethical codes and state laws to our utmost abilities, with your well-being always our first priority. We assess, diagnose, and treat you and your loved ones with honesty and authenticity. We also believe you and only you get to determine what your health care needs are, and we are here to help support you in your personal growth.


Couple Therapy and Marriage Counseling Are Not Covered in Most Cases


In addition, most insurance companies do not cover relationship issues even though they are usually the primary source of client problems. In order for providers to get sessions covered for couples, there has to be a billable diagnosis applied to one of the people, known as the "identified patient." In order to act in accordance with insurance company requirements, the provider has to argue that the spouse or partner is only in the session in order to support the person with the diagnosis in receiving help for his/her/their problem, rather than the relationship patterns that are leading to relationship distress for both partners. Unfortunately, this often leads to providers getting the therapy covered through dishonest reporting when in actuality, the couple is being treated as a system for relationship distress.


As relationship experts, we at Heart Space Counseling Center know that many, if not all, of the symptoms you struggle with in your day to day life stem from your relationships, past and present. We want to help you and your spouse or partner create the relationship of your dreams. We are committed to being a neutral and unbiased presence in the treatment of your relationship stressors. We also understand that past trauma, depression, and anxiety create major relationship challenges and are trained in a variety of modalities to help you overcome these issues as a team or as individuals depending on what is most helpful in your treatment.


"Identified Patients" (i.e. Scapegoats or 'The Individual Who Gets the Blame')


As mentioned above, the "identified patient" is the person in therapy who the insurance companies will cover. Rather than the whole family or couple system being considered the "patient" (wherein each member is viewed as contributing to problems that create symptoms and challenges for the whole system), a situation is created where one person has to be documented as being the main problem in the family or couple. In just one session, providers have to determine who in a couple or family this person is with only about 45 minutes worth of conversation in order to get your session covered by insurance benefits. This can lead to unfair scapegoating and/or misdiagnoses in a person's permanent medical record.


At Heart Space, we recognize that you and your loved ones engage in patterns that create challenges for each person and the relationship or family as a whole. No one person is seen as the "bad guy." We maintain a commitment to helping you see how no one is to blame, and yet each person contributes to relational distress or success. We are here to help you keep yourselves accountable and grow in awareness around your relational issues. We also focus on your strengths and recognize that no label can account for the whole picture!


Deductibles


In many cases, you must meet a deductible (sometimes several thousand dollars) in order to use your insurance benefits for therapy. In these cases, private pay is the only option. At Heart Space we are glad to help you submit your superbills to insurance in order to work towards fulfilling your annual deductible if you elect to do so. Speak with your therapist to learn more.


Out of Network Reimbursement


Many insurance companies have plans which include coverage for out of network care. Coverage differs plan to plan but is often around 20% to 50%. You may elect to submit your superbills for out of network reimbursement by speaking with your therapist. Therapy is also eligible for payment using a health savings account (HSA) or flexible spending account (FSA).


Flexible Funding for Your Care


At Heart Space, we have numerous options to help therapy to be affordable! We offer rates consistent with or slightly less than the average cost of providers in the Denver area. We also offer package pricing to create discounts, sliding scales, and pro bono sessions. Therapy is also eligible for payment using a health savings account (HSA), flexible spending account (FSA), or with the Care Credit. Talk to your therapist to learn more about your options for funding your care!


We hope that this article can help you to make an informed decision about whether or not to use insurance to cover your services. Call for more information or with questions. We are ready to help!

(720) 515-9103


10 views0 comments

Recent Posts

See All

Comments


Commenting has been turned off.
bottom of page