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How to Use Your Out-of-Network Insurance Benefits to See a NYC Psychiatrist

Updated: Dec 10, 2019

Most high quality private practice psychiatrists in NYC do not accept insurance directly. Low reimbursement rates from insurance, delays in receiving payment, and onerous and arbitrary paperwork requirements can make it very difficult for a private practice to offer the quality of service your child deserves while accepting insurance.

Even within large hospital systems and clinics where insurance is accepted, there is a push to shorten time spent with patients and increasing use of midlevel providers such as nurses and PAs instead of Board Certified Child Psychiatrists. Your child deserves excellent mental health treatment--and you should not have to compromise on the quality of your care due to restrictions placed by your health insurance.

Luckily, many families can access high quality psychiatric care using out-of-network benefits. Patients pay the doctor directly, and then submit a copy of their bill to their insurance company. Depending on the insurance benefits, families will be reimbursed for part or all of their costs directly by the insurance company. If you have a PPO insurance plan, you likely have out-of-network benefits. Your psychiatrist will provide you with excellent care that driven by you or your child's needs rather than restrictions placed by insurance companies.

How to Use Your Out-Of-Network Benefits:

Call your insurance company (the number is located on the back of your insurance card) and confirm that you have out of network benefits.

Important Questions to ask your insurance company:

What is my out-of-network deductible?

This is the amount of money that you are responsible for paying before your insurance plan will start reimbursing you for out of network medical expenses. You will have an individual deductible, as well as a family deductible. For example, if your out of network individual deductible is $500, you need to spend $500 before insurance will begin to reimburse your expenses. If your family deductible is $1000, then after this amount is spent on any family members, you will be eligible to receive out of network reimbursement.

What is my co-insurance rate?

This is the percentage of out-of-network expenses a patient is responsible for, after deductibles have been met. For example, if your plan has a 20% coinsurance rate, and a $500 out of network deductible, your insurance will reimburse you 80% of your bills after the first $500 spent. So, for a $400 follow up visit, you can expect to be reimbursed $320. The true cost of this visit will only be $80.

What is my out-of-pocket maximum?

This is the maximum amount of money you have to spend out of network, after which the insurance company will reimburse your visits 100%.

Insurance companies may ask what CPT codes will be billed--the common procedure codes for initial evaluation is 90792, and for follow up appointments is 99213+90834.

Find out what paperwork you need to submit to get reimbursed. Many insurance companies will allow you to submit your claims online. Your psychiatrist will provide you with a superbill that has all the information necessary for reimbursement.

What to do if you don't have out of network benefits:

If you need to use an in-network provider, you can obtain a list of providers from your insurance. Keep a log of doctors that you call--oftentimes, these lists are outdated, and include many psychiatrist who no longer take insurance or are not taking new patients. If you are unable to find a doctor who takes your insurance, or if you make an appointment that is weeks or months away due to lack of sooner availability, call your insurance and explain your efforts. If they are not able to find a doctor that meets your needs, you can request that they cover the expenses for an out-of-network psychiatrist. You can also demand that your child be evaluated by a board certified Child Psychiatrist. You may have to advocate for your child and spend a long time on the phone, but do not compromise on the quality of care you receive.

I hope this guide is helpful. Your child deserves excellent mental health treatment. The standard of care is treatment with a board certified Child and Adolescent Psychiatrist and you should expect to spend at least 30 to 45 minutes with your doctor at follow up visits. My practice will always provide you with the necessary documentation to get reimbursed by your insurance, and can help guide you through this process.

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