Out Of Network Reimbursement Questions

About 2 months ago I decided it was time to begin therapy so I started looking for therapists.

I wanted in person for privacy reasons, which made it very difficult to find a provider. I went on ZocDoc and there were ZERO providers in my network (Premera BCBS) that were accepting new patients.

I went on my insurance's website and called a few of the therapists they listed and I got 3 in a row that were not accepting new patients.

Then I called my insurance to ask about out of network coverage, where they told me they would cover 70% and I would be responsible for the remaining 30%, after I met my $600 out-of-network deductible.

That seems reasonable to me and I find a therapist and start working with them 2x per week, $250 per session.

I submit every receipt for reimbursement I get on the same day I receive it, but the claims are taking a long time to be processed.

Fast forward, I have now had 9 sessions and have spent $2250. I get my first claim processed by BCBS where they are only covering $103 per session.

I call them and they said they only pay 70% of this "allowed amount" and that is $103.

They admitted they may not have told me that before and are going to consider reprocessing my previous claims at rules they told me over the phone, but going forward they wont.

I am at a loss / not sure what to do.

Even if I could find an in-network provider, I don't want to have to start over with a new therapist – and that doesn't change the fact that I couldn't find one before.

I also do not want to be spending $175 per session when I thought it would be $75 – that is $800 more per month than I had budgeted / planned for.

Does anyone have any advice? Is there a way I can negotiate with my insurance to cover a higher amount? $103 is laughably low for NYC. FairHealthConsumer.org said that a "reasonable" rate for therapy in NYC is $300.

submitted by /u/bam2403
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