Out of Network FAQs
What are out of network benefits?
Healthcare providers will often contract with insurance companies and are then “in-network.” Other healthcare providers may not contract with an insurance company (there are many reasons for this) and provide “out of network” services. Your insurance company may provide “out of network” benefits. This generally means that if you would pay the cost of the service up front, but then can submit to your insurance company for reimbursement for some or all of the cost. The amount of reimbursement varies depending on the plan.
How do I check my OON benefits?
Your insurance’s website will usually list out of network benefits on their website. Prior to seeing your OON provider, it’s a good idea to call your insurance company to see if your specific policy has OON benefits, and if so check if there are any requirements for reimbursement. For example, your insurance may require you to have a referral from your doctor in order to qualify for reimbursement. Some questions you should ask when you are on the phone:
How much of my deductible has been met this year?
What is my out-of-network deductible for outpatient physical therapy?
What is my out-of-network coinsurance for outpatient physical therapy?
Do I need a referral from an in-network provider to see someone out-of-network?
How do I submit claim forms for reimbursement?
How do I get reimbursed?
Once any prerequisites are met (i.e. getting a referral from your provider if necessary) you would pay for your physical therapy appointment at the time of service. Your therapist will provide you a superbill which you can then use to submit for reimbursement. You can do this yourself, or utilize a service such as Reimbursify to make this process easier. Your reimbursement amount may depend on your deductible, coinsurance, and cost for the service.
Why would I pay to see an OON provider?
My focus is 100% on you
Empower Physiotherapy is an out of network practice because we believe that high quality physical therapy is best delivered with you, the client, being the center focus of the care being delivered. Insurance companies will often limit how many visits are covered, or poorly reimburse for therapy which results in shorter treatment sessions, seeing more than one patient at a time, or both.
You want highly personalized care
I provide one on one sessions that generally last 45+ minutes. This allows us to focus on you and the issue you’re working to recover from. If your therapist is dividing their attention among 1-2 other clients at the same time, how focused are they on your issue? Or if you have a 25 minute session with a therapist instead of 45+ minutes, did you get the same amount of care or time?
You have a high deductible plan
These are becoming more common. If you have a deductible of $6,000 and are unlikely to meet your deductible over the course of the year, an out of network can be a cost effective way to access high quality care.
You have good out of network benefits
If you have good out-of-network benefits, your insurance company may reimburse you as much as 80% of each session fee, depending on your plan and the therapist’s rate. In some situations, using your out-of-network benefits can actually be more affordable or comparable to your standard co-pay to see an in-network therapist.
Privacy
If you would prefer not to disclose your health information to your insurance company (which would be required for in-network or reimbursement for out of network), you can choose to pay privately for services.