Why Isn’t My Superbill Paying for Therapy?

What’s a Superbill?

You’ve taken that first step – reached out to a therapist who happens to be an out-of-network provider with your insurance company. The therapist assured you she’d give you a receipt (Superbill) to submit to your insurance so that you could be reimbursed for payment for her services.

So you filled out the insurance company’s claim form, attached the Superbill, and sent it off. You waited patiently for almost a month. Finally, you received an Explanation of Benefits (EOB) from your insurance company, stating that they won’t be reimbursing you at all!

What Happened?

1. It’s possible that the Superbill is missing key information. Superbills need to contain your identifying information (name, date of birth, etc.) and a diagnosis. If  your diagnosis isn’t codable, as per the DSM-5/ICD-10, insurance won’t pay. The Superbill also has to contain the therapist’s information, including location/address, her NPI (provider number), and tax ID (for tax purposes). Finally, the Superbill must contain a date of service and CPT (current procedural technology – the type of service provided) code. If even one item from the above is missing, the insurance company can refuse to reimburse you. In most cases, a corrected Superbill, with all necessary information, can be resubmitted, and this might resolve the issue.

2. You don’t have out-of-network benefits. Some insurance plans will only pay for in-network services. If you don’t have out-of-network benefits, you can only see in-network providers, unless you are willing to pay the full amount for all services rendered.

3. You have a deductible. A deductible is the amount you must pay before your insurance starts reimbursing you for the money you laid out. High deductibles are trending these days, which increases your responsibility/decreases reimbursement throughout the year. We sometimes see out-of-network deductibles as high as $5,000 or $10,000. That’s a lot of money to shell out before you are reimbursed, so it’s important to consider this before agreeing to work with an out-of-network provider.

4. You’ve met your deductible, but the allowed amount is just a fraction of your provider’s fee. Each insurance company has a list of “allowed amounts” for services. They do their research and come up with an amount that is “usual and customary” for a particular service or CPT code. For example, they might decide that $150 is reasonable for therapy in the South Florida area. Let’s say your therapist charges $200/hour, and you are responsible for 50% of each visit, as per your out-of-network benefits. The insurance company decides that they’ll reimburse based on the $150 rate, not necessarily what your therapist charges and what you paid. That means that you’ll be reimbursed (once you meet your deductible) $75 for each visit, not the $100 you might have been thinking from the start.

Check the Facts

Therapists commonly market themselves as out-of-network providers and solicit clients with the idea that services will be reimbursable.

In many cases, they are not.

Do your research regarding your plan parameters and make sure that your provider is including all necessary information on your Superbill. As a courtesy, some providers will reach out to your insurance company before you get started to help you make sense of your benefits. If they offer this service, as we do at Gatewell, take advantage of it! Professionals can help translate insurance-speak into a language that makes sense. You’ll learn if you have out-of-network benefits and what they are. Finally, if you do decide to proceed with an out-of-network provider, see if you can get a Superbill after your first session. The more quickly you submit the Superbill, the faster you’ll get a response. We always tell our clients, nothing about insurance benefits are guaranteed. When your Superbill is processed, you’ll have definitive information about your benefits and ultimate responsibility.

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