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I am interested in a specific LPC (Licensed Professional Counselor) because I like their model and services, but they are out of network. I have very limited understanding in the medical/insurance field so my questions may come off rudimentary (or just confusing :).

How feasible is it for a counseling group to "apply" for in-network status? What are some of the reasons why behavioral professionals are not in network with insurance companies?

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1. How feasible is it for a counseling group to "apply" for in-network status?

Generally, this is pretty easy. Every insurer will have different specific methods, but generally it will come down to how many members covered by the insurance are likely to visit that provider (there's little point in contracting individually with a practice 6000 miles away from their main region, and never visited by members), and whether or not the provider can/will accept the rates the insurer offers.

Some providers also decline to contract with insurers because the burden of doing so is too high for them (too much bureaucratic back-and-forth, too many prior authorizations required, too much hassle resolving bills, etc.).

Other criteria may apply, again specific to each insurer, which may preclude the provider from being in the insurer's network. For example, a surgeon with a disproportionately high mortality rate (compared with similar surgeons in the network and region) may be summarily rejected for contracting with a particular insurer. There is very little downside to asking about contracting.

2. Why are behavioral professionals not in-network with insurance companies?

This one is too broad to answer in the general case. There are countless reasons why an insurer might not contract with a specific provider. Maybe they can't agree on rates, maybe the provider doesn't have a credential that the insurer requires for that specialty, maybe market consolidation (on either side) makes contracting unattractive for some broad, market-competition perspective, maybe the provider uses methods that the insurer thinks are ineffective, and numberless others.

It could simply be that neither the insurer or the provider have approached each other about contracting.

There may also be an arrangement you're not aware of. Some insurers just don't cover some services (if they don't cover behavioral health issues, then a behavioral health-focused provider is not likely to be in their network). Some insurers use what's referred to as a carve-out, where that insurer doesn't cover the conditions directly but "buys" that coverage from a different insurer, which handles those claims but may have its own network which doesn't match your primary insurer's. In the U.S., this has long been a common practice for behavioral health coverage (often to manage premiums for members which don't use those services).

3. What is the best method for paying an out of network LPC?

It depends on how your insurance policy handles out-of-network providers. What I would do, in order:

  • Check with the insurer about what rates they pay for out-of-network services in this category.

    This may be explained in your plan documentation (not necessarily very clearly), but even if it isn't the insurer should be able to quickly determine this.

    In addition to the rates they pay directly to the provider, your cost-sharing may change as well (out-of-network providers typically feature higher copays and deductibles than in-network, and may have other service exclusions). If out-of-network services are not covered at all in this case, then going through the insurance is probably not going to be helpful.

  • Check with the provider about how they handle patients without insurance coverage.

    Lack of coverage is a pretty common issue, especially when it comes to networks. This provider almost certainly has policies in place that describe what rates are charged to patients without coverage. If those rates are affordable for you, then simply not using the insurance may be an option. It's frequently the case that special sliding-scale rates are available for patients without insurance (or with insurance that's not adequate).

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The main reason providers are usually not in a network is because they can get enough business without the help of the insurer and they don't want to accept the rates the insurer is offering.

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