At Pathways, we work outside of insurance restrictions and follow the Private Pay model. While many use their PPO insurance to cover therapy costs, others may not like the limited therapist options or the limited availability and services provided by in-network insurance-based therapy practices. In such instances, you may want to fully or partially pay for therapy yourself, allowing you the ultimate freedom to hand-pick your therapist and better dictate your treatment.
Why do some therapy practices accept insurance while others do not? And is there any option in the middle? (Yes!!!…we’ll get to that in a moment)
Can you tell me about therapy practices that take insurance?
Therapy practices that take insurance must establish a binding contract with each insurance company (Anthem Blue Cross PPO, Cigna PPO, etc.). In this contract, the therapy practice agrees to 1) take on the full responsibility for billing, claims, and disputes without compensation, 2) submit regular updates and paperwork to justify continued therapy, 3) follow insurance-dictated restrictions on therapy (therapeutic approach, number of sessions, format, etc.), 4) submit to audits, 5) accept lower pay rates, and 6) maintain records, including mandatory mental health diagnosis, which will then stay as a permanent part of your medical record that insurance providers can use in their assessment of future benefits.
What is a Private Pay (pay-out-of-pocket) therapy practice?
Private pay is when the individual pays for therapy themselves without going through their PPO insurance. This allows freedom from insurance-based restrictions and utmost privacy (insurance cannot access records without your consent) and puts you in full control of your healthcare decisions.
You mentioned an option in the middle… what is it?
The good news is that some PPO insurance plans allow for “out-of-network” providers. (Pathways Family Therapy is an out-of-network provider!) These plans are generally PPO and POS plans. These allow you 1) the freedom to choose your own therapist, and 2) partial reimbursement from your insurer. In short, you can have the freedom to hand-pick your therapist and get partial reimbursement for therapy sessions! For example, if you are looking for an Anthem Blue Cross PPO therapist, you would look for an out-of network provider, like Pathways Family Therapy to obtain some reimbursement for the expense.
| Insurer | HMO reimbursement | PPO reimbursement | Pathways’ Status |
|---|---|---|---|
| Aetna | None |  | Aetna PPO therapist |
| Anthem Blue Cross | None | | Anthem Blue Cross PPO therapist |
| Blue Cross Blue Shield | None | | Blue Cross Blue Shield PPO therapist |
| Cigna | None | | Cigna PPO therapist |
| United Health Care | None | | United Health Care PPO therapist |
Can you walk me through the Superbill submission process?
Pathways will send you a monthly “Superbill” (example below), which contains a list of your appointments/services for the month, diagnosis, billing info, and all necessary tax/licensure info. This Superbill is what your insurance company needs to reimburse you for your Pathways appointments. You can typically submit your Superbill electronically through your insurance portal. From there, they review and reimburse.
*We encourage you to contact your insurance company’s “member services” department or check their website to confirm benefits and reimbursement procedures. Most insurance providers have an online member portal that allows you to easily upload your Superbill. Online submission is usually the easiest option (instead of mail or fax) as there is nothing to print, mail, etc. Insurance typically takes 2-4 weeks to process your request and send you your reimbursement.
How much can I expect to get back from my PPO (or POS) insurance therapy?
As of Winter 2024, rates range from 30-50%. Most of our clients see reimbursements in the 50% range. We’ve even seen some reimbursed 100%.
Are there any restrictions?
Insurers require a diagnosis in order to qualify for reimbursement as a “medically necessary” treatment. Some insurers do not cover couple therapy or marriage counseling (though they do cover individual therapy with a partner present).
Can I use my HSA to pay for PPO insurance therapy?
Absolutely. Many of our clients use their HSA account as their primary payment method, which is billed following each session. (We offer session invoices and receipts upon request, in addition to the automatic Superbill)
We hope you find this information helpful and will happily answer any further questions you may have. Don’t hesitate to reach out, whether you have PPO insurance questions or want to schedule an initial consultation. We love what we do and are eager to meet you!
