Contemptible insurance reimbursement for out-of-network psychotherapy.

December 1, 2014 12:41 PM

The BlueCross BlueShield plan I've had for a few years "allows" only $78 of the $180 that my out-of-network therapist charges. Other companies can't/won't tell me what their allowed amount would be. Does your plan "allow" more than mine does? I just don't understand how they can say that the "reasonable, usual and customary charge" for a therapy appointment with a Ph.D. therapist is $78, because that's just ridiculous. Am I missing something here? Or is this just the insurance companies being $&%#?!*@.
posted by early one morning to Health & Fitness (14 answers total)

Remember that the charges you pay for out of network care are often markedly different from negotiated prices that large insurers pay for the same services. Therefore, even though a PhD therapist in your neighborhood might never charge you, the individual, $78, presumably they're basing it off of the negotiated rates they would pay to a therapist if you saw someone in network.
posted by treehorn+bunny at 12:49 PM on December 1, 2014 [2 favorites]

That sounds about right. I can call my mom and get her to give me the rundown - she takes most of the major carriers - but they are, I think, all about $75, give or take. She doesn't (I believe can't) charge her insured patients more than the reimbursement, but her rate for out-of-pocket patients is around $150.
posted by restless_nomad at 12:51 PM on December 1, 2014 [1 favorite]

After a $25 patient responsible copay that seems reasonable enough. The doc shouldn't be asking you for any more than the copay but that's an opinion and not necessarily contractual (out of network) or a legal issue.

Charging full price for out of pocket patients is how you make up the difference. Sliding scales for income is how you make it up humanely...MDs get the most in my experience. PhD doesn't necessarily mean much IMO.
posted by aydeejones at 1:07 PM on December 1, 2014

And my MD psychiatrist / pseudo therapist makes about $85 if I recall correctly, after my copay. She makes more on periodic appointments that might take 30-45 minutes more than usual. The insurance company is basically paying what they believe to be reasonable based on the expected increase in patient volume brought on by making it affordable, and based on what medicare pays. $180 is only a fair market value when your parents bear to pay it. In an insurance situation that price is simply how they balance the lowered reimbursement for insured patients. That's the sucky system we have and it's basically everybody's fault (providers and payers). Hence, ACA.
posted by aydeejones at 1:12 PM on December 1, 2014 [1 favorite]

I think that's what my insurance was paying for my IN network therapist back in the day. I made up some of the difference on a sliding-scale basis (ie wrote her a check for some of the rest, depending on my income and our number of sessions per month).

Agreeing that it's a broken system.
posted by ldthomps at 1:22 PM on December 1, 2014 [1 favorite]

I'm also with BCBS (of MA) and they allow $138 per therapy session, but I suspect it also has to do with your zipcode. After deductible the member is responsible for 35% if it's out-of-network.
posted by Dragonness at 2:05 PM on December 1, 2014

I just dealt with this myself and it was extremely frustrating. My therapist offered to charge me based on a sliding scale but it took several phone calls with a lot of wrong information to find out what my insurance company would cover for an out-of-network provider. In the end, I wound up asking around and rolling the dice, estimating what I thought the insurance company would cover (no one wouldn't commit to a figure) and then negotiating a sliding scale rate with my therapist. I finally got back an explanation of benefits and they are covering about $87 per session.
posted by trixie119 at 2:22 PM on December 1, 2014

FWIW, my current insurer (Anthem, which is also a BCBS affiliate) has gone even further with their handling of mental health coverage. It's no longer a co-pay for me. It's an out-of-pocket expense, applied to my deductible. The out-of-pocket expense will, of course, reflect whatever Anthem and the provider have negotiated. Still, I certainly can't afford a cost like that every week.

I'm currently paying $10/week at the Psych Dept. Practicum Clinic at the local university. It's as good as any actual counseling office I've been to.
posted by Thorzdad at 2:56 PM on December 1, 2014

So two of the past three years I have developed a decent relationship with a therapist and then "used up" my behavioral health benefit and had to start paying out of pocket. In both cases (different practices in different states) the therapist asked me to pay what they would have gotten from the insurance company, which was $80/visit. One of the insurance companies involved was in fact BCBS.
posted by fantabulous timewaster at 2:56 PM on December 1, 2014

I made up some of the difference on a sliding-scale basis

This question has been correctly answered (the reimbursement in the OP is approximately on-par with all insurance companies and is not unreasonable). However, I feel compelled to point out that this sort of "extra" payment is entirely unnecessary. An "in-network" therapist has agreed that the insurance's negotiated payment is a sufficient payment for services provided. The "difference" is exactly $0, and there's no reason to pay a therapist beyond what has been negotiated by the insurance company. In fact, a therapist requesting reimbursement beyond the negotiated rate is "balance billing", which is illegal in almost all states.
posted by saeculorum at 3:02 PM on December 1, 2014

..."balance billing", which is illegal in almost all states.

Well, sort of. That restriction pertains largely to HMOs. Some states also apply the restriction to PPOs. Very few of the states include out-of-network providers in the restriction.

There are also the "health insurance for $20 a month!!! Use any doctor!!!" outfits who don't fit into either category, and most definitely DO allow balance billing.
posted by Thorzdad at 3:11 PM on December 1, 2014

Reasonable and customary charges are a scam because they are manipulated by the insurance industry. See for example the 2009 settlement in New York (NYTimes link) after the attorney general sued United Healthcare for using a company it owns to determine reasonable and customary charges. Since then, things have gotten even worse (NYTimes link). Here are some related legal actions the AMA has been involved with.

I'm not sure what you can do about it that will have any effect. Maybe complain to your state insurance regulator?
posted by medusa at 3:46 PM on December 1, 2014 [1 favorite]

Also, saeculorum's information doesn't apply to out-of-network benefits, which are the topic of the question here. There has been no rate negotiated between the therapist and the insurance company.
posted by medusa at 3:48 PM on December 1, 2014 [1 favorite]

To be clear, my comment about balance billing was only with respect to ldthomps' comment. I didn't want a reader of this thread to think that paying a therapist beyond a negotiated in-network rate is a common or accepted practice.
posted by saeculorum at 4:28 PM on December 1, 2014 [2 favorites]