Using Out-of-Network Benefits

Like most psychiatrists in Boston who are not hospital-based, I am not "in-network" with any insurance companies. As a result, you will be billed at time of service for your care, and I will not coordinate directly with your insurance company. Many, but not all , insurances may reimburse you for some or all of the fee you pay using your "out of network" benefits. The precise amount of reimbursement varies significantly based on the type of insurance (see some examples below).

1. Verify your out-of-network benefits

The first step is to call your insurance company (the number should be on the back of your ID card) and ask if they provide coverage for “out of network psychiatric care.” If it is available, specifically ask:

1. Is there a deductible? How much? And how much have I paid so far already this year?

2. Is a referral required to see an out-of-network psychiatrist?

3. How many sessions per calendar year will the plan cover?

4. What percentage of the costs will insurance reimburse (sometimes called coinsurance)?

5. Is reimbursement based on my doctor's fees, or is reimbursement based on a standard schedule of fees?

6. What is reimbursement for the following billing codes?

   • CPT 99205 + 99354 (initial evaluation)

   • CPT 99212 and 99214 (medication follow-up)

   • CPT 90833 and 90836 (therapy follow-up)

2. Submit a "superbill" to your insurance company

At your request, I will provide you with an itemized bill of session dates and billing code for treatments provided (a document called a "superbill"). You submit this directly to your insurance company

3. Receive reimbursement from your insurance company

Your insurance company will mail you a check to reimburse a portion of the fees you paid

Examples of out-of-network benefits:

This is the insurance information for Harvard University Students. This insurance has a $250 deductible, with a 30% coinsurance for mental health outpatient visits. This means that the patient pays the first $250 on their own, and following that insurance pays 70% of subsequent costs, up to 40 sessions per year. This will significantly reduce the cost of out-of-network psychiatric treatment. Note that the same treatment provided in-network would be free for the first 8 sessions and $35 thereafter.

This is a Blue Cross Blue Shield policy. It also has a $250 deductible. In this case the coinsurance is even lower, at 20%. Note that this insurance continues to make an outdated distinction between "biologically based" and "non-biologically based" mental health conditions.

James Luccarelli, MD, DPhil Psychiatrist Boston, MA