Paying Out of Pocket for Psychiatry: Superbills and Out-of-Network Reimbursement

For Patients & Families
Written By Sonia Mia Diaz, MD

If your psychiatrist is out of network, you may still get part of the cost back: you pay at the visit, then send your insurance plan a superbill, an itemized receipt with the codes it needs to review the claim. How much comes back depends on three things: whether your plan has out-of-network benefits, how much of your out-of-network deductible is left, and what your plan calls the "allowed amount." A few questions to your plan before the first visit will tell you most of what you need to know.

Why So Many Psychiatrists Are Out of Network

If you've had trouble finding a psychiatrist who takes your insurance, you're not alone. In a national survey, only about 55% of psychiatrists accepted private insurance, compared with about 89% of other physicians. A more recent analysis of claims from 2019 to 2021 found that patients went out of network to see a psychiatrist almost 9 times as often as they did to see other specialists.

Insurance directories add to the problem. In one national survey, about half of people who used a mental health directory found wrong information, such as doctors listed as in network who weren't, or who weren't taking new patients. Those people were twice as likely to end up seeing an out-of-network provider.

Paying out of pocket is a real cost. It can also mean longer visits, a shorter wait and a doctor you chose. Knowing how reimbursement works helps you decide with clear numbers.

What a Superbill Is

A superbill is a detailed receipt. It is not a claim, and your doctor's office doesn't send it for you. It usually lists:

  • Your name, date of birth and the date of each visit

  • The physician's name, credentials, address, National Provider Identifier (NPI) and tax ID

  • Procedure codes (CPT codes) for the type of visit, and a telehealth code if the visit was by video

  • Diagnosis codes (ICD-10 codes)

  • The fee and the amount you paid

You send the superbill to your plan, usually with the plan's own claim form or through its member website. One thing to know: the superbill includes a diagnosis code, and your plan will see it. That is true of any insurance claim. Some people choose not to submit for privacy reasons, and that is your decision.

Questions to Ask Your Plan Before the First Visit

Call the member services number on your card and ask about outpatient mental health benefits from an out-of-network physician:

  • Do I have out-of-network benefits at all? HMO and EPO plans usually cover out-of-network care only in emergencies. PPO and POS plans usually cover some of it.

  • What is my out-of-network deductible, and how much have I met this year? It is often separate from, and higher than, the in-network deductible.

  • What is my out-of-network coinsurance? (For example, the plan pays 60% and you pay 40%.)

  • How do you set the allowed amount for these codes? Can you tell me the allowed amount for a psychiatric evaluation and a follow-up visit?

  • Are video visits covered out of network the same way as in-person visits?

  • Do I need prior authorization?

  • How do I submit a superbill, and what is the deadline after the visit?

Write down the date, the name of the person you spoke with and a reference number for the call.

How Reimbursement Is Figured

Plans don't reimburse a share of what you paid. They reimburse a share of their allowed amount, the most they will count for that service. Out-of-network coinsurance is your percentage of that allowed amount. The difference between the doctor's fee and the allowed amount is yours to pay. This is called balance billing.

Here is an example with made-up numbers. Say a visit costs $300, your plan's allowed amount is $200, you've already met your out-of-network deductible, and your coinsurance is 40%:

  • The plan pays 60% of $200, or $120.

  • You pay the other $180: your 40% of the allowed amount ($80) plus the $100 above it.

If you haven't met your deductible, the allowed amount counts toward it, and the plan may pay nothing until it's met. Early in the year, it can take several visits before any money comes back. To see what a visit might cost you with your own plan's numbers, try our cost estimator.

Other Ways to Lower the Cost

  • HSA or FSA. Psychiatric care is a qualified medical expense under IRS rules, so you can usually pay with a health savings account or flexible spending account. Check with your account administrator.

  • Tax deduction. If you itemize, medical costs above 7.5% of your adjusted gross income may be deductible, and psychiatric care counts. A tax professional can tell you whether this applies to you.

  • Network gap exception. If your plan has no in-network psychiatrist available within a reasonable distance or wait time, you can ask the plan to cover an out-of-network doctor at in-network rates. Plans handle this differently, and many want the request, and sometimes prior authorization, before your visits. Approval is up to the plan.

  • Good Faith Estimate. If you aren't using insurance to pay, federal law entitles you to a written estimate of expected charges when you schedule at least 3 business days ahead, or when you ask. If a bill ends up at least $400 above the estimate, you can dispute it within 120 days of the bill through a federal process (there is a $25 fee).

If You Have Medicare

Most of this guide is for people with private insurance or no insurance. If you have Original Medicare and see a doctor who participates in Medicare, the doctor's office bills Medicare for you, and you don't need a superbill. Our guide Does Original Medicare Cover Psychiatric Care by Video? explains what you pay. For help choosing a Medicare plan, Virginia residents can contact VICAP and Florida residents can contact SHINE.

How Welmivia Can Help

Dr. Diaz sees adults located in Virginia or Florida by video, for medication management of depression, anxiety, ADHD, trauma, sleep problems and mood changes with aging. You must be in Virginia or Florida during each visit. Private-pay patients are seen out of network:

  • You receive a Good Faith Estimate when you schedule.

  • You pay at each visit and receive a superbill afterward to send to your plan. Our cost estimator can show what your plan may pay back. Your plan decides any reimbursement; Welmivia does not file claims for private-pay visits.

  • Visit fees are generally HSA and FSA eligible.

  • Current visit fees are listed on our FAQ page.

Welmivia is also a participating Medicare practice and bills Original Medicare directly. We are not able to see patients with Medicare Advantage or Medicaid.

To get started, book an evaluation or call 434-623-0003 for a short call to check fit and coverage. Medicare patients can use our Medicare request form.

What to Take Away

  • An out-of-network psychiatrist doesn't always mean paying the full cost; a superbill lets your plan reimburse part of it if you have out-of-network benefits.

  • Before the first visit, ask your plan about your out-of-network deductible, coinsurance and allowed amount.

  • HSA or FSA funds, a network gap exception and a Good Faith Estimate can all help you plan for the cost.

Welmivia is not a crisis service. If someone is in danger, call 911. For a mental health crisis, call or text 988.

Sources

This guide is general information, not medical advice for your situation.

Sonia Mia Diaz, MD

Sonia Mia Diaz, MD, is the founder and medical director of Welmivia, a physician-led psychiatric practice that cares for adults in Virginia and Florida by video, including patients with Original Medicare. Her work focuses on diagnostic clarity, careful medication management, and coordinated care with primary care physicians.

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