Out-of-Network Therapy: All You Need to Know

Deciding to get help and then figuring out what type of therapy you need is an excellent first step in improving your mental health. The process doesn’t end there, though. Understanding how insurance works and the differences between using in-network or out-of-network mental health care providers are big pieces of the puzzle, too. 

Whether a therapist is in-network or out-of-network will significantly affect your cost of care. If you decide to go out-of-network, expect to pay much more for a therapy session because compared to in-network providers, out-of-network therapy costs are much higher.

Knowing how to navigate insurance benefits effectively is essential — and understanding the pros and cons of out-of-network mental health coverage will help you decide if the cost savings of staying in-network are worth it. 

Research shows that using an out-of-network provider is more common in mental health than it is in general healthcare — keep reading to learn what the phrase out-of-network therapist really means and if it’s something you should consider. 

What Does “Out-of-Network Therapy Coverage” Mean?

Out-of-network therapy coverage means seeking care from a therapist or mental health service provider who’s not contracted with your insurance provider, which translates to a higher cost of care since the prices haven’t been negotiated to keep them down. 

Not all insurance policies are the same. There isn’t a single, hard and fast rule about what you’ll pay if you go out-of-network, and some plans will pay part of the cost of therapy. That said, even if your plan covers a portion of your out-of-network cost, you’re still most likely going to spend more for a therapy session than you would staying in-network.  

If you’re considering an out-of-network provider, look at your plan benefits to understand what this ultimately means. Some plans, for example, make you pay 80% of an out-of-network provider’s bill, which can make therapy feel expensive. Others state you must meet a deductible before any reimbursement kicks in.

Out-of-Network vs. In-Network Therapists

The biggest differences between in and out-of-network mental health coverage are that staying in-network saves you money and simplifies the billing process. However, it can also limit your options when it comes to the mental health service providers you can see, making it more challenging to find the right fit for your unique needs. 

Like most things, each route has pros and cons. Understanding them can help you decide on the best path.

Pros & cons of seeing an out-of-network therapist

Choosing an out-of-network therapist might cost you more, but certain perks might make it the best choice in some cases.

Pros of out-of-network therapists:

Access to a wider array of mental health professionals

Larger pool of specialists to choose from if you have niche needs

Potential for higher quality care or a better fit

Can be easier to tailor sessions to what you need versus what’s covered under your plan

Possibility for quicker access to care because you’re not limited to providers with long wait times

Cons of out-of-network therapists:

The obvious drawback is cost, which is typically higher

Higher costs can limit how much therapy you can afford

Navigating out-of-network therapy reimbursement claims (if your insurance covers part of your therapy) can be complex

Submitting paperwork to health insurance companies for a partial reimbursement can be time-consuming

Pros & cons of seeing an in-network therapist

Choosing to seek care from a therapist in your insurance network can be easier and cheaper, but it’s important to weigh the pros and cons carefully to determine if the savings are in your best interest.

Pros of in-network therapist:

Cost savings — insurance generally covers a larger portion of the cost of care from in-network providers

Reduced cost can allow for more sessions

Peace of mind knowing your insurance company has vetted a therapist’s qualifications and experience

Simplified billing process and no need to navigate complicated out-of-network therapy reimbursement claims

Cons of in-network therapists:

Fewer choices and options for providers

Potential for reduced access to specialized/niche services

More limited access to preferred gender, cultural awareness, and other qualities you might be seeking in a therapist

Possibility for longer wait times

Plan limitations on how many sessions or what type of therapy is covered

“Understanding the costs associated with seeing an out-of-network therapist vs an in-network therapist is important when choosing a therapist. At the same time, there can be other factors to consider: where you live, wait lists, and therapeutic specialties that influence your decision.”

– Talkspace therapist, Jill Daino, LCSW-R

Understanding Your Out-of-Network Benefits

Once you understand the key elements of out-of-network benefits, you’ll feel more confident in making your decision — both financially and in terms of achieving the best outcome from your therapy journey. Choosing an out-of-network therapist might mean paying more upfront, but it can also potentially offer specialized care you might not otherwise be able to access. 

Use the following steps to figure out if staying in-network or seeking an outside provider is best:

Contact your insurance provider

This is the first step in deciding. Your insurance provider can explain your Summary of Benefits, give you options for in-network providers, and help you understand your cost if you choose to go out-of-network. 

To get started, locate the customer service number on the back of your insurance card or log into your account on the website.

Find out your specific coverage

Ask several questions about your coverage so you fully understand what to expect. You’ll want to ask your health insurance company about things like:

What percentage of each billable session is covered (for both in- and out-of-network providers)?

What is your deductible (the amount you must pay before insurance or reimbursement kicks in)?

Is there a cap, also known as the “allowed amount,” on costs or how many sessions you can have per calendar year?

Are there any types of therapy that aren’t covered under your plan?

Ask about the reimbursement process

Make sure you understand how to get reimbursed if you decide to use a therapist who’s not in-network. 

Do you pay the provider upfront and then get reimbursed? 

Will the provider submit services to your insurance and then bill you the difference? 

What forms do you need to fill out and submit for reimbursement?

How to Get Reimbursed for Out-of-Network Therapy

The more information you have about the process, the less stressful it will be to find the right therapist. If you decide going out-of-network is something you’ll ultimately do, make sure you know how payments and reimbursements work. It’s common to pay the therapist and seek reimbursement from your insurance company. If this is what you need to do, the following will help:

Contact your insurance company and ask about their specific process for submitting your claim.

Find out if you need prior authorization or a referral from your primary care doctor.

Understand your insurance plan’s reimbursement requirements — do you need a superbill for therapy sessions from your therapist? Should they provide you with an invoice?

Make sure you fill out the claim forms accurately. Every field, form, and requirement should be complete, and if you’re unsure about something, don’t hesitate to ask for clarification. Missteps here can result in delays or denial of your claim. 

Be prepared to follow up after you’ve submitted a claim. Insurers often need additional information or details about a submission. Without proper diligence and follow-through, your reimbursement might be stalled. 

Take detailed notes on any communication you have with your insurance provider, including dates, times, and names of anyone you speak with. Also, record what you’ve been told and note any timelines they offer so you can circle back if needed. 

Explore a Diverse Network of Online Therapists

Finding the right therapist can be a daunting experience, but it’s worth your time and energy. When you find the perfect person who best meets your needs, you’ll know you made the right decision. 

Whether you end up staying in-network or deciding to pay out-of-network therapy costs to someone outside your preferred provider list, fully understanding your options ensures you find the path that best aligns with your mental health needs and your financial situation. 

As you look for a therapist, don’t forget about online therapy. Talkspace is a convenient online therapy platform that offers affordable, accessible treatment from experienced and qualified mental health professionals. Talkspace also makes getting help easy, with a streamlined process that gives you access to a large, diverse network of therapists who can meet your mental health needs. 

Get online therapy covered by insurance and see how Talkspace can broaden your access to therapists by reaching out today.