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Insurance vs. Private Pay




The good and the bad


There are many clinicians that have chosen to use a private pay model only for their practices. In other words, they do not accept insurance for reimbursement. Some practices provide a document called superbills. This document is basically an itemized reciept that contains other information about your provider that you will need in order to submit the out of network claims to your insurance carrier. There are clinicians that accept select insurance plans and also offer private pay/ super bill options. It truly depends and a lot of thought goes into these decisions. Things clinicians consider are population served, location of services, niche of services, and the required training for those areas. Just as there are specialists in the medical fields, there are specialists in the mental health field as well which require extensive continued education and research. When we see a specialist in the medical field our out of pocket expenses are typically higher than a general practioner.


What are the differences in these structures?


Well for one thing a solely private pay practioner accepts only direct payments that are the responsiblity of the client. They do not receive superbills for OON (out of network) reimbursements. However the benefit of this method is client privacy. This also means that insurance can not audit or decide whether or not the client receiving services is eligible or if the treatment is necessary. We will get into necessity of treatment in a minute. They simply see their therapist and move on.


A practioner that offers super bills for private pay clients does have to continue to add a diagnosis and various coding for the insurance company. If you are using insurance you have a diagnosis. Insurance requires one to be able to use. Yet not everyone seeking therapy fits criteria of a diagnosis which is why some practitioners choose not to use this method or take insurance.


Many practioners are also opting out of insurance because insurance determines length of sessions and reimbursement fees based on the session length which can vary greatly from company to company, thus impacting financial stability and lead to clinician burn out.


Accepting insurance does open the doors for many individuals seeking therapy services. We all know the premiums paid for health insurance so having the ability to utilize this is helpful. However it is not always as it appears. Under one's general plan there are other sub categories. Mental/behavior health as one. If you opt to use your insurance, you may have a high deductible that needs to be met before insurance will reimburse at a percentage or full fee. This deductible may be specific to the category of Mental Health or the over all plan. It is also possible that the fee the client is responsible for to go towards the deductible is higher than the therapists private pay fee.


For example: Your deductible may be 6,000. Filing the claim towards the deductible may run you 150 per session out of pocket. This would be 40 sessions at 150 if you were only using your insurance for therapy. That is close to weekly sessions from the start of the year, with likely under 10 sessions covered at full cost under insurance. Then this starts over at the first of the year. Again this is an example, and fees vary depending on the insurance company. Now if you use your insurance often for other health needs then use of this type of plan is beneficial because you will likely get more sessions covered.


There is a benefit to use of insurance, but it is important to know what type of plan and benefits one has to determine which way is going to be the most beneficial. Also once the deductible is met, there may be a co-insurance fee associated with the plan, which means you pay a percentage of the session fee even meeting the deductible. Some plans only include a co-pay, which tends to be the best option for individuals. It is generally a fixed amount paid per session regardless of services, with tiers from general to specialists indicated on your card.


Breakdown Pros and Cons

Private Pay

Pros

  • Flexibility with time spent in session

  • A wider net of therapists

  • Potential reimbursement

  • No diagnosis required (if no superbills are present)


Cons

  • Out of pocket expenses

  • Reimbursement varies and not guaranteed


Insurance Based

Pros

  • Utilizing benefits

  • Meeting deductibles

  • Partial or full coverage of sessions

  • Allows accessiblity to mental health services for varied financial levels


Cons

  • Limited net of therapists

  • May still have INN (in network) expenses

  • May have limited number of approved therapy sessions

  • Will have a diagnosis for claims submission


As a clinician that accepts private pay with providing superbills and accepts some insurance plans, I can empathize and value what clients experience. Most clincians have experienced these same things themselves and/or for their family members. There are pros and cons to any of the choices. Yet it is important to have some understanding behind this and allow yourself to make the decisions based on this information that is right for you and or your family.


Therapy is a helping field, but it is also a livelihood clinicians depend on. It is okay to talk finances with your provider and it is helpful to have an understanding of the systems in place.


Which way will you choose and Why??










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