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Reimbursement 101: Demystifying Out-of-Network Reimbursement


Understanding medical reimbursements can be challenging, particularly when it comes to out-of-network services. To help clarify this process, let's explore a scenario in which Vanessa seeks therapy from an out-of-network provider and tries to understand how her reimbursement is calculated.





Vanessa's Out-of-Network Therapy Experience

Suppose Vanessa spends $200 to see a therapist who does not accept her health insurance (a PPO plan she obtains through her employer). Depending on the treatment she receives and the type of insurance plan, her insurance company might say the amount she paid exceeds the "allowed amount." For out-of-network services, the patient is usually responsible for paying the difference.

In this example, the allowed amount is $160.

Applying the Allowed Amount to Benefits Policy

The allowed amount is what gets applied to Vanessa's benefits policy. Most plans have an out-of-network deductible that has to be fulfilled first. This means she pays the initial expenditures in full for these services.

In this example, her deductible is $750 and has already been fulfilled, so the calculation moves to the next step.

Taking the Out-of-Pocket Maximum into Account

Since her deductible has been fulfilled, the entire allowed amount gets processed according to her plan benefits. However, there's one more stop on the way to reimbursement: the out-of-pocket maximum (OOPM).

Vanessa's out-of-pocket max of $3,750 has NOT been reached, so we proceed to the next step.

Calculating the Reimbursement Amount

Now we can finally calculate her reimbursement amount! In this case, her policy pays 70% and she pays 30% (often called coinsurance).

A reimbursement for 70% of $160 (in the amount of $112) is processed for this appointment.

Conclusion

Navigating out-of-network reimbursements can be confusing, but understanding the process can help patients like Vanessa make informed decisions about their healthcare and potentially save money on medical expenses. It's essential to be aware of your insurance plan's allowed amounts, deductibles, and out-of-pocket maximums when seeking out-of-network services. If you have questions or concerns about your reimbursement, don't hesitate to contact your insurance company for clarification.

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