Out-of-Network Psychiatry: What Patients Should Know About Insurance Reimbursement

Many patients who are looking for a psychiatrist encounter providers who do not accept insurance. This can be immediately discouraging, particularly for patients who have good insurance coverage and expect to use it. But understanding how out-of-network reimbursement actually works can significantly change the picture.

Why many psychiatrists do not take insurance

Insurance contracts for behavioral health services typically reimburse psychiatrists at rates considerably below market, particularly for longer or more complex sessions. Administrative requirements — prior authorizations, claims processing, utilization review — add substantial overhead. For solo psychiatrists who provide longer, integrated sessions combining medication management with psychotherapy, the economics of insurance contracting are particularly challenging.

What out-of-network benefits means

Most commercial health insurance plans include some level of out-of-network mental health benefits. The key concepts are: the out-of-network deductible (what you must pay before insurance begins reimbursing, typically $500–$2,000); the allowed amount (the insurer's internal benchmark for a service, which may be less than the provider's actual fee); and the coinsurance rate (typically 50–80% of the allowed amount, paid by the insurer after the deductible is met).

How superbills work

Out-of-network psychiatrists provide a superbill — a detailed receipt including CPT procedure codes, diagnosis codes, provider NPI number, and fees. You submit this to your insurer and they send you a reimbursement check. You pay the provider's full fee at the time of service and receive the reimbursement afterward.

How to find out what your plan covers

Before assuming out-of-network care is unaffordable, call the member services number on the back of your insurance card and ask: Do I have out-of-network behavioral health benefits? What is my out-of-network deductible, and how much have I met? What is your allowed amount for CPT code 90792 (initial psychiatric evaluation) and for 99214 with the 90836 add-on (follow-up with psychotherapy)? What percentage of the allowed amount will be reimbursed? What is my out-of-network out-of-pocket maximum?

HSA and FSA funds

If you have a health savings account (HSA) or flexible spending account (FSA), psychiatric fees — including fees paid to out-of-network providers — are typically eligible expenses. Using pre-tax dollars reduces the effective cost of care by your marginal tax rate.