The Complete Guide to Out-of-Network Nutrition Reimbursement
So, you just found out your dietitian (ermmm that might be me… sorry!) doesn’t accept health insurance anymore and you are overwhelmed once you hear “out-of-network.” Sounds like a complicated mess you don’t want to deal with, right? Hang tight my friend! I’ve been in your shoes and I’m here to break it down to you as simple as possible!
What’s the deal with out-of-network providers?
When you see a healthcare provider, there are two types: in-network and out-of-network.
In-network providers are contracted directly with your insurance company, which usually means lower costs for you. An example of an in-network provider is Doherty Nutrition! You see their dietitian, they bill insurance on your behalf, and insurance tells you it’s covered under your benefits or that you may owe a copay or deductible amount.
Out-of-network providers don’t have this contract, which means you pay the provider directly for their services. An example of an out-of-network provider is me (hi! 😊) and the nutrition counseling services (link to nutrition counseling page) I provide here.
Wait, so why would a provider NOT contract with health insurance if it means lower cost for YOU??? Speaking personally, here are just a few things I learned during my time accepting insurance:
Billing insurance is a full-time job, so to accept it a clinician might have to hire someone to help with billing or take time away from their own work with clients (or personal time!) and the clinician isn’t able to afford this or simply not interested in doing it.
Insurance sets rates for what they pay clinicians, and this rate may be lower than what the clinician needs to make ends meet. Some insurance companies don’t adjust the rates they pay clinicians, despite inflation or other financial indicators (crazy, right!?).
Insurance sets the rules for the clinicians, so if a clinician accepts insurance they are bound by their contact and not their own. For example, they may not be able to provide services at certain locations (like a client’s house or a grocery store) where a clinician who doesn’t accept insurance can. In another scenario, insurance simply won’t cover certain services a clinician may want to provide, so they wouldn’t get paid if they were contracted with insurance.
How are out-of-network benefits covered?
I wish I could tell you!!! Unfortunately, every single health plan covers this differently so there’s a lot of variation. Here are two ways you can find out:
Contact Your Insurance Company: Go to your health insurance portal online, look at your insurance card, or give them a call. You’ll want to ask them, “What is my coverage for out-of-network nutrition counseling?” If they ask for more details, provide the procedure code of 97803 for nutrition counseling.
You might hear something like, “You have a $10,000 deductible and once this is met the service is covered at 60%.” Then, you’ll think…. Huh??? If that’s you (because that was me!), ask or look to see if you’re deductible has been met or how much is remaining to estimate how much you’ll have to contribute to your deductible first.
Take a Test Run: Scouts honor…. I did step one and didn’t understand the representative, so I decided to just see my out-of-network provider for therapy and see how was covered. I naively thought my provider’s cost was $140 and since insurance typically covered ~$80-90 for an in-network provider that my balance would be the difference… NOPE! I discovered through my test run that my benefits were quoted right, but I just didn’t understand them. So – my provider charged my $140, I paid $140, and insurance applied this amount to my deductible of $10,000 for out-of-pocket services. Lesson learned…
This can be a great strategy when you don’t want to spend the time talking to insurance and have the money to potentially owe the full amount charged by your out-of-network provider. Trial and error!
What do I do with the superbill?
A superbill is a basically a receipt given to you by your out-of-network provider for your healthcare visit. It lists services and costs, which you need to get reimbursed from your insurance company. You may or may not receive this automatically from your provider, so make sure you ask for it!
To get reimbursed, check if your insurance covers out-of-network. If yes, send your superbill to them - which usually involves sending an e-mail or message with your superbill attached or filling out a form. Then, you wait. It might take a little while (personally mine took about 3-4 weeks!), then the amount might get applied to your deductible or even better you get some money back in your pocket!
That’s an Out-Of-Network Wrap!
And that’s it! You’ve got the basics of out-of-network reimbursement. It sounds daunting at first, but it’s simple once you know how!
Comment below with any tips or tricks you’ve learned with out-of-network reimbursement to help others!