Seeing an Out-of-Network Psychiatrist in New York: How Reimbursement Works

Adults seeking ADHD care in New York often end up weighing a psychiatrist who is outside their plan's network. Plans with out-of-network benefits will pay something toward those visits. How much is the part people misjudge, usually because they expect the plan to reimburse a percentage of what they paid. It reimburses a percentage of a different number.

The three numbers that decide what you get back

The fee. What the psychiatrist charges. You pay it in full, usually at the time of the visit.

The allowed amount. HealthCare.gov defines this as the maximum amount a plan will pay for a covered health care service. For out-of-network care, the plan chooses the method. Some plans base it on a percentile of local charges. Others use a percentage of the Medicare rate, which is generally far lower than private fees in New York.

Your cost sharing. The out-of-network deductible you must meet first, then the coinsurance percentage you owe on the allowed amount.

The difference between the fee and the allowed amount is called the balance. HealthCare.gov describes balance billing as a provider billing you for the difference between the provider's charge and the allowed amount, and notes that only preferred (in-network) providers are barred from doing so. With a clinician you chose outside the network, the balance stays with you, and it does not usually count toward your deductible.

A worked example with made-up numbers

These figures are invented to show the arithmetic. They are not anyone's fee and not any plan's rate.

If the out-of-network deductible has not been met, the plan pays nothing for that visit and credits the $200 allowed amount toward the deductible. A plan described as paying 70 percent out of network can therefore return well under half of what you spent.

What New York requires insurers to tell you

Since 2015, New York-regulated insurers have had to explain how they cover out-of-network care and how they calculate payment. They must give examples of their reimbursement calculations for common out-of-network services, and those examples have to be shown against the usual and customary cost. In New York that benchmark is the 80th percentile of charges for the service in the same specialty and area, as reported by FAIR Health, an independent nonprofit.

That benchmark is for comparison only. FAIR Health states that it does not set usual and customary rates or out-of-network reimbursement amounts, and that insurers make those determinations themselves. A plan can disclose that its payment equals a small fraction of the benchmark and still be following the law.

Two other New York rules are useful:

• Consumers may ask for a plan option that pays out-of-network services at 80 percent of the 80th percentile benchmark. Insurers must offer one on request unless exempted, and such plans may cost more.
• A clinician who is not in your network must tell you so before treating you and must give you a cost estimate if you ask.

These rules do not reach self-funded employer plans, which are governed by federal law. How to tell which kind you have is covered in does insurance cover adult ADHD care in New York.

Superbills and the claim

A superbill is the itemized receipt you send to your plan. No New York statute defines it, but in standard claims practice it carries the clinician's name and identifying numbers, the date and place of service, the procedure (CPT) codes, the diagnosis codes and the amount paid.

The codes matter because the allowed amount is set per code. Codes commonly used in adult ADHD care include:

• 90792: psychiatric diagnostic evaluation with medical services;
• 99213, 99214, 99215: follow-up medical visits of increasing length and complexity;
• 90833 or 90836: psychotherapy added to a medical visit;
• 96130 to 96137: psychological and neuropsychological testing.

Ask the practice which codes it expects to bill for a first visit and for follow-ups. Then check your plan's claim filing deadline and whether it wants claims through a portal or by mail.

Questions to ask your insurer before the first visit

1. Do I have out-of-network benefits for outpatient mental health care? Is my plan fully insured in New York or self-funded?
2. What is my out-of-network deductible, how much have I met, and does it reset on January 1 or on a plan-year date?
3. What is the allowed amount for CPT 90792 and for 99214 in my ZIP code, and how is it calculated?
4. What coinsurance applies, and is there an out-of-network out-of-pocket maximum?
5. Are telehealth visits with an out-of-network clinician reimbursed on the same terms?
6. Is prior authorization needed for any of these services?
7. Can you send me your written example of out-of-network reimbursement for a psychiatric visit?

Record the date and reference number of the call. You can look up the local charge benchmark for any code and ZIP on FAIR Health's consumer site and set it beside the allowed amount your plan quotes.

What does not protect you here

New York's surprise bill law and the federal No Surprises Act cover narrow situations: emergency care, an out-of-network provider at an in-network hospital or surgical center, and referrals by an in-network doctor made without your written consent. Choosing an out-of-network psychiatrist's office yourself is none of those.

There is one separate route to in-network cost for out-of-network care. If your New York-regulated plan cannot offer a timely in-network appointment, an access complaint can lead to an approved out-of-network referral. It has specific steps and limits, explained in the 10-business-day rule.

The Good Faith Estimate, if you skip insurance

People who are uninsured, or who decide not to submit claims, are treated as self-pay under federal rules and can ask the clinician for a written, itemized Good Faith Estimate. It is due within 1 business day when the visit is scheduled 3 to 9 business days out, and within 3 business days when it is scheduled further ahead or requested without scheduling. A bill at least $400 above the estimate can be taken to federal dispute resolution within 120 calendar days.

For a side-by-side view of the two paths, see in-network or private-pay psychiatrist. This practice's own billing arrangements are on the fees and insurance page.