Here’s an important thing everyone with insurance needs to understand: Insurance companies use some “creative” ways to determine the basis of what they’ll cover. It’s not just that your plan says it’ll cover, say, 80% of the cost of psychotherapy — it’s 80% of what they say psychotherapy costs. That’s an important number.
(They get crafty about how they come up with that number, and even what they call it, by the way. Sometimes they use something called Usual, Customary, and Reasonable (“UCR”). Or reasonable market value… a number they can basically just make up. Or they’ll use a percentage of Medicare rates as the basis for how much they’ll pay — even if you aren’t eligible for Medicare, which is specially negotiated insurance for people 65 or older, younger people with disabilities, and people with End Stage Renal Disease.)
Keep in mind that they use that number — what they say psychotherapy costs — to calculate your reimbursement. For example, if your insurance plan says it covers 80% of psychotherapy fees, what that really means is they’ll pay 80% of what they say the typical fee for psychotherapy is.
The catch is that there are very few regulations for how they determine that number. And, they usually won’t tell you (their customer!) what that number even is — calling it “proprietary information.”
Good news, though! Thanks to numerous class action lawsuits, and legislative work on healthcare laws, there are consumer rights websites where you can see what an objective source says the typical fees are in your area.
The sites are Healthcare Bluebook and Fair Health Consumer. Here’s how to use it to look up the Typical Provider Charge (another term for UCR) for psychotherapy in our area:
- Enter our zipcode
- Enter the procedure code; 90834 is the procedure code for individual outpatient psychotherapy, 45 minutes, or you can ask your therapist what code they’ll use.
- If given an option, click “Out-of-Network Reimbursement.”
- Look for “Cost Breakdown” (ignore the first few rows you see on the page — those includes other charges like hospitalization).
There you have it! Now you know the real typical cost for psychotherapy in our area.
For those not wanting to do the legwork, Healthcare Bluebook listed a “Fair Price” for 45 minute outpatient therapy in Salina as $215 (April 2020).