Out-of-Network Speech Therapy Benefits

Out-of-Network Speech Therapy Benefits

Recently, I discussed the generally unfavorable state of affairs around health insurance for speech therapy services. Despite this, all is not lost. Not by any means! Many of my own clients are able to take advantage of out-of-network speech therapy benefits for health care reimbursement, which can provide a significant savings for families. In this same vein, a previous post of mine covered Flexible Spending Accounts (FSAs) and Health Savings Accounts (HSAs). Today’s post focuses on what parents need to know in order to access those precious out-of-network speech and language therapy benefits. As with anything insurance-related, initially it can be a bit complicated. The hope is that, armed with this information, you will be better able to get the benefits you actually pay for, and in as timely a manner as possible.

Choosing a health plan

Out-of-network benefits are usually associated with a Preferred Provider Organization (PPO) which allows the consumer greater choice in having their health services at least partially paid for. These plans do tend to be more expensive, so it is crucial to weigh your family’s individual and unique anticipated health expenditures for the upcoming year when choosing a plan.

If you anticipate your child needing, for example, significant services from a speech pathologist, then a PPO may be a sensible choice.

Speaking purely from the perspective of a New York State resident who has recently been covered by a health insurance plan offered through the Affordable Care Act (“Obamacare”), I can say that generally speaking, Obamacare plans do not offer out-of-network speech therapy benefits. Read the fine print of your plan, as boring as that can be. There may be several types of PPO plans to choose from so run the numbers for each plan and see what will save you the most money.

Call your insurance company first

Get someone on the phone who can explain exactly what your reimbursement rates for speech therapy are. What is the amount of money you must pay (i.e. your deductible) before your benefits kick in? Does this amount apply to each member of your family or can they be pooled together? Ask your insurance company to explain this. Once your deductible is met, how much of each speech therapy session will the insurance cover? Is it 60% or 70%? Does this apply to your therapist’s full fee or to an “allowed” rate per session? For example, let’s say your therapist charges $125 for 45-minute session. Do they pay, for example, 70% of $125 or is that a lower figure, like $85? This is important to clarify to figure out your true total cost.

Get your therapy to help

Although most private therapists, at least in New York City where I practice, do not directly participate with insurance, they should stand ready to help you in any way they can to access your out-of-network benefits. This usually takes the form of making sure you receive detailed invoices describing the services rendered. Often, specific information is required such as:

  • Provider Name
  • Provider NPI number – this is assigned by the government as a unique identifier for each provider
  • Provider Tax ID number – this is often, but not always, required
  • Patient name
  • Diagnosis or ICD-10 code — a speech therapist should include a diagnosis for your child’s speech or language challenge
  • Dates of service
  • Procedure of CPT code for each date of service
  • Fee charged for each procedure

If some of this information is missing in your claim, it may get delayed or denied. So to save yourself aggravation and significant time, it is a good idea to make sure that this information is included in your claim before you submit it. These guidelines can have a meaningful impact on your family’s bottom line as you get your child the speech and language therapy services you deserve. The bottom line here is to keep the lines of communication very much open; talk to your insurance company, talk to your therapist – there are ways to make this vital service affordable!

Parent's Guide to Speech & Communication Challenges
Find your speech solution
Financial Resources