Superbills: How Does Superbill Math Work?

A superbill is a detailed receipt you can submit to your insurance provider to seek reimbursement. You pay your therapist directly and are reimbursed a portion by your insurance later. But how are insurance companies actually calculating what you will get back? 

Don't want to know the hows but do want the number? Check out Nirvana's Out-of-Network Benefit Calculator here. 

This is how the math is determined:

1.  Determining the "amount allowed" by insurance companies. Insurance companies set a price for what they believe therapy costs. This is generally much lower than the average fees in the Bay Area (and generally) and lower than what would provide cost of living. So if you pay $180 for your therapy and for instance, your United insurance set the price at $100, you will be reimbursed only that $100. The additional $80 will not be reimbursed or calculated as part of your deductible, insurance, or co-pay.

2. Determining your out-of-network deductible. Most people have a deductible--meaning they need to pay a certain amount before insurance kicks in anything. Deductibles exist for out-of-network and in-network benefit. So if you have a $1000 deductible, you have to spend that much out of pocket before insurance pays anything. Submitting Superbills for out-of-network benefits adds to your deductible, but they will only track the "amount allowed" not your actual cost. 

3. Determining Co-insurance and Co-Pays. Co-insurance is percentage based and co-pay is a flat fee. So if you have a 20/80 co-insurance from United whose "amount allowed" is $100, you will get reimbursed $80 per session. If you have a co-pay of $10, you will be reimbursed $90. 

Is your head spinning yet?? Universal Health Care please. 

A common example may look like: 
Therapist fee: $180
Amount allowed by insurance: $100
20/80 Co-insurance
Amount that counts toward your deductible = $80 
Amount your are reimbursed per session after meeting your deductible = $80

What type of therapy does insurance reimburse?
Insurance covers therapy that is "medically necessary." This means therapists have to give you a diagnosis. This makes some people reasonably uncomfortable and it may be a reason to keep insurance out of the picture altogether. This is something to discuss with your therapist. 

Commonly used diagnoses include:
F41.1 Generalized anxiety disorder
F43.20 Adjustment disorder, unspecified
F43.10 Post traumatic stress disorder, unspecified 
F43.12 Post traumatic stress disorder, chronic
F33.0 Major depressive disorder, recurrent, mild
F32.1 Major depressive disorder, single episode, moderate
F34.1 Persistent depressive disorder
F90.9 Attention deficit hyperactivity disorder, unspecified type

Using insurance also means that insurance companies can ask for your medical records from your therapist to determine whether treatment is medically necessary and is in alignment with what they consider medically necessary treatment for whatever your diagnoses is. 

Back to Superbills: What questions should I ask my insurance?
Call the number on the back of your health insurance card and ask for “member services." Ask these questions to verify out-of-network coverage:

• ​What is my yearly deductible? Has it been met or how much more until my deductible is met?
• How many sessions per year does my plan cover?
• How much does my insurance plan reimburse for an out-of-network provider for CPT code 90834 (for individual services) or CPT code 90847 (for couple's services)? This is also know as "amount allowed."
• Does my insurance plan cover Z codes for couples therapy?
• What is my co-payment?
• Do I need prior authorization?
• Do I need approval from my primary care provider? ​

What can you expect after submitting a superbill?
It can typically take your health insurance 2-4+ weeks to process your superbill. They will either pay the full amount of services minus your copay, or they will put this amount towards your deductible.

Looking from a trauma therapist in Oakland, CA? Learn more here.

Looking for a queer couples therapist in Oakland, CA? Learn more here. ​

What Will You Get Back From Your Superbill