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Forum
-> Household Management
-> Finances
amother
Honeydew
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Wed, Aug 05 2015, 2:08 am
I would very much like to consider using Hands On OT (Guttman) for my child but can't see paying out of pocket and they don't work with the DOE. They did say they have given people invoices to submit claims to their insurance companies out of network, but they did not know whether people were successful with this or which insurance companies were involved.
If you have been reimbursed for ANY out of network OT, please share which insurance company you used and any other information that could be helpful! Thank you!
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saw50st8
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Wed, Aug 05 2015, 7:33 am
I have CIGNA and we have gotten reimbursed. We first had to meet our out of network deductible and then got 70% back based on our plan coverage.
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nylon
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Wed, Aug 05 2015, 8:25 am
Yes. BCBS (not Empire though, a different BCBS)
It is approved according to the same criteria as in network, since we have a PPO. HOWEVER, we get back 70% of the "usual, customary, and reasonable" charge, after my out of network deductible, and it was subject to the same visit caps. So in the end I got back almost nothing, since I have an out of network deductible of $1000. My insurance caps at 12 visits of OT per plan year.
Also, the balance billing, meaning that you must pay the difference between the allowed charge and what is billed, means that the effective paid percentage may be 50% or less. You can easily have a situation where the OT bills $125 a visit and insurance says it's worth $75. So they pay 70% of $75, $52.50. You are liable for $72.50 unless the OT agrees to discount their rate. Some out of network providers will negotiate but the lack of contract means they have no obligation to accept UCR as payment in full.
Most insurances use the UCR rule to limit exposure but the deductible and visit caps will vary. So you may see something back. But, you can be like me, and covered on paper--those visits all counted towards our deductible and we did see a bit back, but we paid the bulk of the cost.
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