Why Are So Many Therapists Out-of-Network And What Does That Mean?

Navigating the World of Therapy: Understanding “Out-of-Network” Care

Embarking on a therapy journey is a significant step towards well-being. As you explore your options, you might encounter the term “out-of-network therapist.” This can seem a bit confusing, so let’s break down what it means and why you might find that many highly qualified therapists operate outside of insurance networks.

What Exactly is “Out-of-Network” Therapy?

Simply put, an out-of-network therapist is a mental health professional who is not contracted with your specific health insurance plan. When you see an in-network therapist, they have agreed to accept a pre-negotiated rate with your insurance company for their services. This often means you pay a co-pay or meet your deductible, and the insurance covers the rest of the agreed-upon fee.

With an out-of-network therapist, the dynamic is different. You typically pay the therapist’s full fee upfront at the time of your session. You then have the option to submit a claim to your insurance company for potential reimbursement, according to your plan’s out-of-network benefits. The amount your insurance company reimburses can vary significantly depending on your specific plan.  Skylands Wellness will help you look up and understand your out-of-network benefits, providing an estimate of your final costs.  Additionally, Skylands Wellness can submit your claims on your behalf electronically for most plans, eliminating this extra step for you.  

So, Why Are So Many Therapists Out-of-Network?

You might wonder why a therapist would choose not to participate in insurance networks. The reasons are multifaceted and often stem from a desire to prioritize client care and professional autonomy:

1. Maintaining Clinical Autonomy and Quality of Care:

• Unrestricted Treatment Planning: Insurance companies often have guidelines and limitations on the number of sessions, the length of sessions, and even the types of therapy they deem “medically necessary.” Out-of-network therapists have the freedom to tailor treatment plans precisely to their clients’ unique needs without these external constraints. They can offer longer sessions, more frequent sessions if clinically indicated, and utilize a wider range of therapeutic modalities.
• Focus on Client Well-being, Not Insurance Mandates: Their primary focus remains on providing the most effective care for their clients, rather than adhering to insurance company protocols that might not always align with the client’s best interests.

2. Fair and Sustainable Compensation:

• Negotiating Fair Fees: Insurance companies often reimburse therapists at rates that are significantly lower than their standard fees. For experienced and specialized therapists, these rates may not be sustainable or reflect the value of their expertise and the cost of running a private practice (including ongoing training, supervision, and administrative overhead).
• Avoiding Administrative Burden: Dealing with insurance companies can be time-consuming and administratively complex, involving pre-authorizations, detailed documentation, and potential claim denials. By being out-of-network, therapists can dedicate more time and energy to their clients rather than navigating insurance bureaucracy.

3. Specialization and Niche Practices:

• Focusing on Specific Populations or Issues: Therapists who specialize in niche areas or work with specific populations (e.g., complex trauma, eating disorders, perinatal mental health) may find that insurance networks don’t adequately recognize or reimburse for their specialized expertise. They may choose to operate out-of-network to maintain their focus and set fees that reflect their advanced training and experience.
• Offering Less Common Modalities: Certain therapeutic approaches, while highly effective, might not be widely recognized or reimbursed by all insurance plans. Out-of-network practice allows therapists to offer these modalities without being restricted by insurance coverage limitations.

4. Building a Practice Based on Value and Client Choice:

• Prioritizing the Therapeutic Relationship: Many out-of-network therapists believe that the quality of the therapeutic relationship is paramount. By not being tied to insurance contracts, they can focus on building strong connections with clients who actively choose to work with them based on their expertise and approach, rather than solely on network affiliation.
• Maintaining Privacy: While in-network therapists are bound by HIPAA, they do need to share diagnostic information and treatment details with insurance companies for reimbursement. Some clients prefer the added layer of privacy that can come with out-of-network care, especially if they choose not to seek reimbursement.

Is Out-of-Network Therapy Right for You?

Choosing an out-of-network therapist can offer significant benefits in terms of finding the right specialist and potentially receiving more tailored care. However, it’s essential to consider the financial implications.

Here are some questions to ask yourself:

• What are my out-of-network benefits? You can contact your insurance provider to understand your deductible, co-insurance, and the percentage of the therapist’s fee they will reimburse.  Skylands Wellness has access to an electronic insurance benefit checker and we will provide you with our best estimate of your final costs.  Please reach out to us if you’d like help in reviewing and understanding your benefits.  
• Can I afford to pay the full fee upfront? Consider your budget and cash flow.  Going out of network will often cost morethan in-network treatment.  However, we truly believe you get what you pay for.  If paying the full fee up front is challenging for your family, talk to us about our special payment plans.  For some families, waiting on reimbursement doesn’t work and Skylands Wellness may be able to wait for reimbursement on your behalf.  
• Is the therapist’s specialization or approach particularly important to my needs? If you require specific expertise, going out-of-network might be worth the extra cost.  Skylands Wellness offers specialized care in perinatal mental health, children and families, couples therapy, and trauma treatment.  
• Am I willing to handle the process of submitting claims for reimbursement?  With Skylands Wellness, you likely don’t need to submit your own claims.  Just let us know at the time of booking that you prefer to have the claims submitted for you and we will send you the forms to begin that process.  

In Conclusion:

The decision of whether to see an in-network or out-of-network therapist is a personal one. Understanding what “out-of-network” means and the reasons why many therapists choose this model can empower you to make an informed choice that best aligns with your mental health needs and financial circumstances. Don’t hesitate to inquire about fees and out-of-network options when you’re searching for the right therapist for you. Your well-being is worth the investment in finding the best possible support

Contact Us today for support in understanding your benefits and scheduling your intake with a specialized therapist at Skylands Wellness.