Superbill: What it is and How to Use it for Therapy Reimbursement
Are you wondering “what is a superbill for therapy?” Welcome! You’re in the right place. In this article, you’ll get a breakdown of what a superbill is, so you can determine if using them could be right for you. The billing tea; all from a licensed therapist.
The Basics
Let’s be plain: superbills aren’t bills at all, they’re a receipt for services rendered.
Here’s how using them works:
Client pays their full therapist’s fee upfront
Therapist provides a superbill (aka the receipt for the bill already paid) back to their client
Client submits the superbill directly to their insurance company (or via 3rd party service)*
Insurance company reimburses the client directly according to their out of network benefits
*There are services like Mentaya and Thrizer who facilitate the superbilling process; they take a cut of the reimbursement, while handling things like submission of the superbill (so clients don’t have to), and responding to insurance company rejections.
Superbill for Insurance
Superbills are bills for insurance providers to pay up and pay out for their patients/clients, specifically when they work with providers out of network. If this is news to you, that’s probably because insurance companies don’t really advertise that they do this. They’d prefer for their patients to work with people in network, because then they get to set the fees.
Wait…therapists don’t set their own fees?
Nope! Not when we’re in an insurance network, anyway. Here’s what happens instead:
The insurance company makes therapists go through bureaucratic hoops of paperwork, then they process said paperwork (which can quite literally take months), before using some secret math formula to come up with the rate they think those therapists are worth. What’s in the formula? No idea; a breakdown of the formulas aren’t provided. And, if a therapist ever wants to ask to change their contracted rate, they’re asked why they think they deserve more. That could include what state(s) they serve, time in the field, modalities they provide, populations they specialize in, languages they speak, and so on. And even still…the insurance company won’t say what sways them to increase that therapist’s contracted fee or not. They’ll simply decide the therapist’s rate, and then send out an email with it, as if to say: “here’s what we’re offering, take it or leave it.”
Do insurance companies pay well?
HAHAHAH. Sorry; human reaction from me. That’s a big ol’ N-O-P-E from me, y’all! You see, insurance companies love to collect money, but they don’t really love to dish it out. I liken insurance to extortion: you pay in for “protection” but when the time comes, you may or may not actually get protection/help. I’m guessing you’ve noticed this already.
Let’s all take a moment for a collective cathartic scream, shall we?
What about when therapists are out of network?
We can set our own rates. Ones that mean we don’t have to see a never ending line of clients that we get worse at supporting because we need to make ends meet. I recently heard a therapist say that one of the well-known HMO insurers asked her to see 35 clients a week. THIRTY FIVE. That’s seven clients, five days a week. Can you imagine having SEVEN emotionally loaded, one hour conversations in a day? Five days in a row, every week? Do you think you’d be able to do that and still be okay? Ya…me either. 🥴
So here’s the tension point of it all: insurance providers are asking something impossible. If therapists want to stay in the field and make a living without burning out, we really only have one recourse. To see clients who are willing to pay out of pocket. That way, we remain well and actually helpful. Which poses a challenge. Especially because being a visible enough therapist online for people to find means needing marketing. And, in the duh statement of the century: also means that clients need to have a financial situation that’s a good fit for paying out of network rates. Which is legitimately challenging in the current economy. And, I’d argue, ultimately isn’t helped by the insurance situation; because when we standardly spend money on monthly premiums to insurance providers (which may or may not actually help cover the cost of our health needs), we have less financial freedom to spend our money in other ways. Meaning that even if we want to pay for therapy out of pocket, we may not be able to. At least, not without rethinking our budgeting…and maybe using a superbill.
A Note About Capitalism
Okay, I know, I know, this isn’t technically why you’re here, but humor me for a minute. I want to get thoughtful about how you think about your resources. Because capitalism probably got you twisted. It’s not your fault, but you have a blindspot. You see, most people think of resources as just money (after all, it’s what’s valued most in capitalist society). But the truth is that there are many other kinds of resources too: time, attention, physical health, mental health, social capital, assets/property/objects, etc. We pay with some of these resources in exchange for money without even realizing it. We exchange our time (and lots of it!) for money by agreeing to work; likely our physical and mental health too. Then, because we still need to care for ourselves, we buy things. But sometimes, those things don’t actually provide care. Sometimes they provide things like distraction/dissociation, or other temporary bandaids when we really need other kinds of care.
Weren’t we talking about Superbills?
Yep! Let me tie it all together for you. The more we prioritize making money, the less we care for ourselves and our needs, and the more likely we are to have health problems. Both physical AND mental. Which would be fine if we had a health insurance system which actually used the money we pay them to consistently and ethically support us in meeting our health needs. But, sadly, we don’t. Instead, we have a health insurance system that takes our money, may or may not cover our health services, and then underpays care providers. Which means those providers burn out as they, too, try to make a living.
Okay YEESH, so…what do we do?
It makes sense to take a good, honest look at your health needs and how you spend your resources. And I mean all of them. Then, get honest about how it makes sense for you to use your resources to fund getting your needs met. If you’re burnt out, you might decide you need to take time off work. If you’re feeling disconnected from social support, you might decide to set aside time for a call to a friend. If you have a physical injury, you might decide to get specialty care; same with mental health care. All needs are valid, and considering them as such means we’re more likely to figure out how to get them met.
Practical Superbill FAQs
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That depends on your plan. If you have a Medicaid plan [pssst: states call these different things: in OR, this is Oregon Health Plans (OHP) like HealthShare and Trillium; in CA it’s called MediCal], you won’t be able to superbill. Same with Medicare. Governmental plans don’t allow superbilling whatsoever. If you have insurance through an employer, you’ll have out of network benefits according to the plan you selected when you (or whoever you’re covered under) signed up. These plans run the gamut in terms of out of network coverage; everything from really high deductibles and essentially no out of network coverage to reimbursement for up to 80% of what insurance providers call “the allowable amount” for out of network therapists.
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This is what the insurance company has decided will be the maximum amount of what they’ll cover for out of network reimbursement. Oftentimes, this is lower than the low, laughable rate that the insurance provider would try to pay the therapist if they were in network. And it’s worth noting: if your coverage were to say that you get 80% coverage of “the allowable amount,” you wouldn’t actually get back that much of the therapist’s entire fee. It would be 80% of the “allowable amount” as determined by the insurance company. Which they don’t publish online. They’re typically based off Medicare prices, which, you guessed it, are even lower than the rates they set for their in network therapist rates. Now, before you get discouraged, remember: this might still be worth it. Especially if you happen to have high copays or deductibles for in network providers already.
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There are a few options to choose from:
A) Find your health insurance plan policy documentation. Look at the out of network benefit information. It should tell you your copay, deductible, and coinsurance information for both in and out of network providers according to your coverage. From there, we can guesstimate the “allowable amount” based off recent trends.
B) Call your insurance provider. If you choose this option, you may also be able to get a direct answer about what their “allowable amount” is in addition to the rest of your coverage information. Having this information is the best way to ensure there’s no billing surprises.
C) Use the lookup tool on one of the superbill service websites, like Mentaya or Thrizer. -
Copay: This is what you’d pay for in network services every time you have a session with an in network therapist. It’s a flat fee, and can be different amounts depending on whether your therapist is in or out of network. So make sure you’re looking at the out of network number when figuring out if superbilling could be right for you!
Deductible: This is an out of pocket total for how much you’ll pay before the insurance company starts helping cover costs. These can be for in network and out of network therapists alike, and oftentimes the deductibles are different for in network vs out of network. So make sure you’re looking at the out of network number when figuring out if superbilling could be right for you!Coinsurance: This is a percentage of the overall cost of a service that you’ll be responsible for after your deductible is met. So, if you meet your deductible and have a coinsurance of 30%, you’d pay 30% of the cost of the service’s “allowable amount”, while insurance covers the other 70%.
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Yep! Let’s make things concrete with a proper example. I’ll use my own fees to make it make sense. Let’s pretend that you have out of network benefits that give you a deductible of $1500, which you’ve already met, and a coinsurance of 30% for out of network providers, with an “allowable amount” of $100. With that deductible out of the way, and my current fee of $275/session, you’d pay $30 in coinsurance and $175 to make up for what the insurance company has refused to pay. A total of $205. At least until you hit your out of network out of pocket maximum. After that, they’ll pay the entirety of their “allowable amount”. Then, sessions would be $175 for the rest of the year.
Oh, and if you’re like me and math isn’t your thing, little callout here that there are free tools to do this math.
Superbill: Conclusion
Superbills could lower the cost of seeing an out of network provider, making it possible to work with a therapist that’s not in your insurance network. It all comes down to the specific details in your out of network benefits and what feels accessible in your personal budget.
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