Private Pay and Out-of-Network
Self-Pay Model
We offer private pay services. Meaning you have complete control over your child's therapy plan. There are no session limits or restrictions set by insurance companies.
Out-of-Network Benefits
Many families can be reimbursed through their out-of-network benefits. We provide a Superbill (detailed invoice) for you to submit to your insurance company.
No Insurance Restrictions
Private pay allows us to create a therapy plan that's right for your child, without the limitations or delays that insurance driven clinics often face. We focus on quality, not quantity, and therapy is based on your child's needs rather than insurance approval. Privacy is an additional benefit, we are not obligated to share anything about diagnosis and treatment with your insurance company, school, or anyone else.
How to Get Insurance Coverage
for Private Pay Services
Your insurance may still cover services, and it may be cheaper than seeing an in-network provider.
You will need to check if your insurance has out of network benefits. These are often found with PPO plans.
Even when a practice is “private pay only”, services are typically eligible for insurance coverage. This works a little differently than “in-network” services. It can require a little more paperwork on your part as the patient, but it can be well worth it to ensure you’re able to access treatment with a provider who is a good fit for you.
How “out-of-network” insurance coverage works, and how to go about getting payment from your insurance company for specialty services:
“Private pay only” generally means the same thing as “out-of-network” services. As long as the provider is a certified or licensed speech language pathologist, their services generally qualify for insurance coverage. When a private pay only provider states that they don’t “take” your insurance. This means they won’t submit claims for you, but you can still potentially submit your claims to your plan and get reimbursed. This arrangement is referred to as “out-of-network” care.
Some plans may require additional paperwork to get out-of-network services covered, such as a preauthorization or precertification. This basically means that you need to submit paperwork to insurance before services begin, alerting the insurance plan that you intend to see an out-of-network provider. Even if the diagnosis and service is generally approved by your insurance, failure to complete this paperwork can result in denial of any out-of-network claims. It is important to check if your plan has any preauthorization or other paperwork requirements.
How To Get Out-of-Network / Private Pay Services Reimbursed by Insurance
- Check your plan information to see if you have out-of-network benefits
- If yes, check to see if preauthorization or other advanced paperwork is required
- Contact your plan to get information on how to submit claims to them yourself (snail mail, online through your member portal account, etc.)
- Ask Speech Pathology provider to provide you with a superbill so that you can submit a claim to your insurance company.
- Pay your provider the full amount at the time of service
- Receive a superbill from your provider
- Send the superbill to your insurance plan, following any requirements they have
- Receive a check in the mail from your insurance plan
Our clients find that what we do is so effective that it’s well worth the extra step of submitting for reimbursement. Many are even paying less than they would for an in-network provider.
Examples:
Example with average amounts from in-network providers: The client has a $30 copay for speech therapy and 30 visits allowed per year. This is a common speech therapy benefit through a good insurance plan. The client is seen for a total of 70 sessions (i.e., 2x weekly as many children are) for services costing $30 for the first 30 visits and then $95 per visit after the 30 visits allowed by insurance for a total of $4,700. They were paying $4,700 per year for in-network with their insurance company.
Compared to out-of-network benefits: The client is reimbursed 70% for sessions costing $95 each visit. The total cost after the 70% reimbursement is $1,995, which is far less than the $4,700 per year for in-network services. Even better, the insurance company isn't dictating what the child can work on and has no access to the child's records.