Experience getting an out-of-network provider "preauthorized"?

March 23, 2021 9:16 AM

My husband and I (in the US) were covered under his employer’s health insurance. He has left the company and we are now switching to my employer’s plan. I need to choose between two plans, and the best value for us comes down to whether or not our out-of-network therapists are covered.

(When I say “covered” it’s really 60/40% coinsurance, based on the amount they pay for therapy, but that would still help.) The paperwork I have says it would require “Preauthorization” in order to see an out of network therapist. Do you have any experience getting an out of network provider preauthorized? I’m sure they will try to get me to see their in-network therapist, but is this likely to be something I can ultimately get approved, or is this code for “forget about it”? I know you can’t predict my specific outcome, just looking for some anecdotal evidence. Thanks!

posted by brbmaroon to Work & Money (8 answers total)

Best answer: I live in Massachusetts. I've tried to get out-of-network psychotherapists approved at least twice and I hit a brick wall both times. The second time it happened was particularly galling. The insurers were happily paying $700/session for an in-network provider. That provider moved to California and the provider didn't have anyone to take her place. I found an out-of-network provider that was going to charge me $150/hour. The insurers refused to reimburse for that. I took this through multiple appeals. They'd be happy to continue paying $700 in-network but didn't want to pay $150 out of network.

But this could vary from state to state and insurer to insurer. Have you tried calling the insurance company and talking to them?
posted by Winnie the Proust at 9:23 AM on March 23, 2021

Best answer: "Generally speaking", you call the customer service line, explain your circumstances, and they should give you a form to fill out to send back, and they will decide to give you preauthorization after X days. Follow up if you don't get an answer after X days.
posted by kschang at 9:35 AM on March 23, 2021

Best answer: So, oftentimes this is offered by medical plans as a way to appear flexible. However, the requirements placed on the provider are sometimes so onerous that the providers decline the authorization. It’s a shit ton of paperwork in many cases, and for smaller groups or independent practitioners, just too much.

I’ve sought out of network sites many times, and each time the problem has not been with the insurance company (sort of) but with the provider getting hit with the paperwork reality and then saying “oops never mind.”

This is why the best psychiatrists and therapists often do not accept any insurance at all.
posted by furnace.heart at 9:36 AM on March 23, 2021 [1 favorite]

Best answer: I don't know what state you're in, but one of the disadvantages of using an out of network provider in the states where I've looked at this, is that the out of network provider can balance bill you. An in-network provider has agreed with the insurance carrier to accept, say, $100, for a procedure, of which you are responsible for, say, $30 and the carrier pays $70. An out of network provider might not have agreed to that $100 and might charge $150 for the same procedure, of which your carrier is paying 60% of the "allowed amount" of $100, and the provider is free to charge you the rest (in this example, $90.) I don't know if your therapist would take advantage of this, but it is certainly possible they might.

As far as how likely they are to precertify your request for an out of network therapist, it's hard to say. There are a lot of reasons that plans like to keep people in-network, and some of those are very good reasons indeed: network agreements are one of the only tools that plans have to control underlying health care prices, so if everybody goes out of network then providers don't see any advantage to signing up in a network and agreeing to a schedule of fees. I don't know how aggressive your carrier is likely to be in this and neither do you, and nobody is going to be able to tell you anything you can take to the bank, six months down the road when you're appealing a denial.

So how I would think about it is, is the difference in premiums worth the headache of this not going the way you want it to?
posted by gauche at 9:36 AM on March 23, 2021 [2 favorites]

Best answer: +1 to what gauche said -- some states actually forbid balance billing! Some, as I have learned to the tune of $2500, do not. But you can look up yours here, if that's a concern.
posted by chesty_a_arthur at 9:55 AM on March 23, 2021

Best answer: In case it matters, coverage for out-of-network services often requires that the patient pay up front and then seek reimbursement from their insurance company. In other words, the provider doesn't bill the insurance company directly.
posted by Winnie the Proust at 12:29 PM on March 23, 2021

Best answer: I'd also ask your therapists directly whether they've had luck being successfully pre-authorized by the plans of other patients and whether they're open to doing the extra work to do so for your plans. It still won't be a sure thing, but if they've figured out how to do it for others, they will likely be willing to at least try for you.
posted by quince at 12:31 PM on March 23, 2021 [1 favorite]

Best answer: For what it's worth, the link that chesty_a_arthur shared is good, but the details matter. For example, Texas is listed as having comprehensive balance billing protections, but those protections do not apply to a case such as yours, where you are knowingly seeking services from an out of network provider, and they do not apply to "self-insured" health benefit plans -- that is, plans where the employer, rather than the insurer, is putting up the money to pay claims -- as such plans can only be regulated by Congress due to something called "ERISA Preemption". Yours might be a self-insured plan in which case your state's consumer protections, such as they are, will not apply to your health coverage. It is almost always better, from a financial standpoint, to stay in-network if possible.
posted by gauche at 6:11 AM on March 24, 2021