Insurance Superbills and Out of Network Therapy

Here at Riverbank Therapy, we provide courtesy billing for clients who want to use their in or out of network insurance benefits (read more about this below, and more about our fees and billing practices here). However, many therapists in the field opt to provide clients with superbills rather than doing courtesy billing.

Even if you don’t seek therapy at Riverbank, we’d love to support you in understanding what a superbill is, how they work, and what out of network reimbursement can look like with superbills. We want to support you in feeling confident navigating the financial side of therapy services.

What is a superbill?

A superbill is a receipt from your therapist provided to you after a session has occurred. You can submit your superbill to your insurance carrier for potential out of network reimbursement.

For successful claims processing with your insurance, the superbill must contain at least:

• your name, date of birth, and insurance ID number,

• the date of service for the session,

• the CPT code for the session (for most therapy sessions this is 90791, 90837, or 90834), including any modifiers for the session if it was a telehealth session,

• your diagnosis (yes, even with out of network billing, you must have a diagnosis on the superbill for insurance reimbursement),

• the providers name, license number, NPI number, and tax ID number,

• the fee for the session, and how much you paid.

Some insurers may require more information on a superbill, but this is typically what is required.

Why is my therapist giving me a superbill?

Therapists who are out of network with insurance companies may choose to provide you with a superbill rather than doing courtesy billing (more on courtesy billing below).

Therapists often choose to do superbills because they do not have to navigate the complexities of insurance systems and incur less risk financially. With superbills, the therapist collects the full session fee from you up front, and then you do the legwork to potentially get reimbursed by your insurance company.

What if I don’t HAve or want a mental health diagnosis?

We understand that not everyone wants to have a diagnosis in their medical record. Much of what brings us to therapy is just a result of being a human, and labeling your experience with a diagnosis is not always helpful.

However, a diagnosis is required for in-network and out of network billing for services to be reimbursed by your insurance company. Sessions will not be covered by insurance without one. Unfortunately, this is how the insurance industry in the United States functions, regardless of how your provider handles billing.

If you don’t want to have a diagnosis on file, you will want to opt for “private pay”. This is effectively just paying out of pocket for therapy sessions and not involving insurance at all.

How do I submit a superbill?

Different insurers have different processes for submitting superbills. Most of them have an online member portal where you can fill out a claims form requesting reimbursement and include the superbill (with all of the information listed above, and anything additional your insurance carrier requires). Then you wait for them to process the claim and determine how much was covered by your insurance.

Some HSAs also require you to submit a superbill when using HSA funds to pay for therapy sessions. Check with your specific insurance plan and HSA to find out what is required.

How much will my out of network insurance cover when I submit a superbill?

This depends on your plan. See more on our Insurance 101 page for information about insurance plans, deductibles, coinsurances, and the difference between in and out of network providers.

When you submit a superbill, you’re doing it because your therapist is out of network with your plan. Your therapist should quote you an estimate of your benefits before your first session so that you have informed consent about what therapy will cost for you. Not all providers do this though, so we recommend also calling your insurance carrier to find out what your out of network coverage is.

Most out of network plans have a deductible that you have to hit before insurance begins covering anything.  For example, you may have a $3000 out of network deductible. This means you have to use $3000 worth of medical services before insurance will pay anything. (More on this on our Insurance 101 page). Once you hit your deductible, most plans have an out of network coinsurance. For example, after paying $150 per therapy session until you hit the $3000 deductible, you might then have a 50% coinsurance per session. This means you would pay $75 per session, and your insurance would reimburse you for the other $75.

However, if your provider is doing superbills, you would have to pay their $150 fee up front, even after you’ve met your deductible, then submit the superbill to your insurance, and wait for your insurance to reimburse you for the $75 (50% coinsurance) that they cover.

Again, we recommend reaching out to your specific insurance carrier to find out what your out of network coverage is.

How do I get reimbursed by my insurance company?

Most insurance companies mail you a check for the covered amount after you submit the superbill and they process the claim. This typically takes around 30 days after you submit the superbill.

What is courtesy billing?

Courtesy billing means that you don’t have to deal with superbills! Courtesy billing means that your provider submits claims to your insurance on your behalf, and then the provider waits for reimbursement.

For our above example, with a superbill, after you met your deductible, you would have to keep paying your therapist $150 out of pocket each session, then wait for your insurance to reimburse you for the $75 covered after your submit the superbill.

With courtesy billing, once you’ve met your deductible in the above example, you would just pay the 50% coinsurance ($75) up front to your therapist, and then your therapist would wait for insurance reimbursement instead.

We do courtesy billing at Riverbank Therapy. We find it to be easier for our clients and increases the accessibility of therapy. More information on how we handle this on here.

INTERESTED IN SCHEDULING A FREE CONSULTATION WITH ONE OF OUR PROVIDERS? FILL OUT OUR CONTACT FORM HERE AND WE’LL GET YOU BOOKED!

WANT TO HEAR MORE ON THIS TOPIC? LISTEN TO TONI TALKS THERAPY EPISODE 2 ABOUT STARTING THERAPY!

Your Guide to Starting Therapy

by Abby Lombardo, LMFT

It’s daunting.

I get it.

Yes, I, too, have had to search for a therapist (therapists seeing therapists who see therapists, it’s a thing) and have just stared blankly at my screen hoping the right someone would fall into my inbox.

In this way, searching for a therapist is like dating: you’re basically courting someone to see if they are trustworthy and make you feel comfortable enough to tell all of your vulnerabilities and still feel accepted by them.

 Actually, it’s a lot like dating.

 It’s also like searching for an apartment or a place to live, you might not know it’s a good fit until you try it out, step into the space, spend some time there…to know if it is a good fit or not for what you’re needing.

That’s the important part: try to focus on what YOUR needs are at THIS time in your life and the kind of person/professional you’re looking to help support your journey.

To aid in this purpose, I’ve devised a “Searching for a Therapist Cheat Sheet” that outlines common words, phrases, acronyms, and questions to help guide your search. It can help to feel informed and oriented to the search process, so that you can focus more on what the professional has to offer YOU.

Ideally, this information is best used in a consult with a provider. A consult is usually a free 15-30 minute meeting (over the phone or virtual) to assess whether you’d like to work together and schedule your first appointment. If the provider’s website or profile page doesn’t advertise that they do consults, don’t be afraid to ask!

Let’s get started with common therapy words used in the search for a therapist, that might not be so intuitive or self-explanatory.

7 Common Therapy Search Words:

1.      Specialty: this is something a professional has added training, experience, and interest in. Usually this includes some kind of certificate, training, and additional letters after their name. It is also probably the clients they have seen and want to see. Pay attention to these, they can be a helpful way to filter through who you might want to work with on a certain issue or topic.

2.      Modality: this is a bit different than specialty in that it refers to the way a therapist conducts treatment, or, how they do therapy. Modalities are therapeutic frameworks, lenses, theories that often guide the professional’s way of doing things in session. See more in the Acronyms section for the names of several common modalities to know about.

*The cool thing? Research shows that it’s not necessarily the modality that brings success in therapy, but the relationship you have with your therapist! So, modality does not make or break unless it leads to you not vibing with your therapist!

3.      Intake: the term for the 1st session. Intake sessions are usually billed at a higher rate than normal sessions as they are used traditionally for assessment, onboarding, orientation, and paperwork. Intake sessions vary from therapist to therapist. Some have you, the client, talk about why you’re coming to therapy and what the issues are you’re experiencing. Some will ask for your family information to get more context. Some will go through a timeline with you of different experiences you had while growing up. Mostly though, they’ll all discuss confidentiality and privacy with you, as well as the exceptions and you will probably be asked about why you’re coming to therapy, what your goals are, and how the therapist can support you.

4.      Scope of practice: this is a lot like specialty and modality in that it is WHAT a professional provider can OFFER you in terms of services. For example, a marriage and family therapist (LMFT) cannot prescribe medications, it is legally and ethically outside of their scope of practice. Make sure you are looking for a provider who can offer you the services you are actually looking for.

5.      Somatic-focused: this term refers to anything body-related. Somatic techniques and modalities often help you learn to work with and regulate the systems of the body: the “flight, fight, freeze” system and the calm/rest/soothe system (for example). A somatic-focused therapist might ask you: “Where do you feel that in your body; can you describe it?” If this feels daunting, they are there to help you every step of the way. They see the body as a source of wisdom and connection. They also see the body as the #1 place that we store all of our emotion, trauma, energy, and pain. There’s a lot you can work with somatically that you might not be able to through talking.

6.      Attachment-based: this refers to a general modality/theory of therapy that examines and explores the way you relate to people and things. Attachment begins when we are infants, depending on caregivers to provide us with what we need to sustain life and be nourished. How we attach/ed to our caregivers can have a lot of sway over how we relate to significant others and even friends. This modality is incredibly informational and slightly Freudian, and most therapists have training in this, though some zoom in and use only an attachment-based lens as their main modality or get extra training in it.

7.      Mindfulness-based: this refers to a therapist who uses present-focused, attention-centering techniques in the therapy session or for the client’s homework to engage the client more mindfully with the here and now, whether that be with your breath or with the uncomfortable, restless feeling you are having. Mindfulness has many, many amazing benefits and can really help with anxiety, mood, and attention issues.

9 Common Therapy Acronyms (in alphabetical order!):

1.      ACT: Acceptance and Commitment Therapy – teaches mindfulness-based coping tools for unwanted/negative thoughts and emotions, while focusing on identifying client’s values and moving towards goals based in the client’s values.

2.      CBT: Cognitive-Behavioral Therapy - probably the most common therapy acronym used these days; explores the connections of the 3 parts of the CBT Triangle: thoughts, emotions, behaviors and how they all interact with each other to build negative cycles and habits. Offers ways to interrupt negative/unwanted thought, emotion, or behavior sequences through practical changes and reframing. Most mental health professionals are trained in this type of therapy.

3.      CPT: Cognitive Processing Therapy – a common therapy for treating PTSD

4.      DBT: Dialectical Behavioral Therapy – a skills-based therapy that offers tools for many things including: self efficacy/assertion, emotion regulation, distress tolerance, receiving feedback, making a decision, etc. Great for someone who benefits from structured therapies.

5.      EFT: Emotionally-Focused Therapy – often for couples, this process-oriented therapy strives to find the vulnerable, intimate spots that we often try to protect out of fear or hurt and uses it to reconnect partners who are struggling.

6.      EMDR: Eye-Movement Desensitization and Reprocessing – this therapy is very cool. It is a somatic-based, trauma therapy that uses your body’s way of processing information to help you work through issues, sometimes without talking about them with the therapist. They teach a lot of coping strategies so that you feel ready for what comes up, too. Essentially, they use what you naturally do in REM sleep in session and utilize bilateral stimulation (sensation happening on 2 different sides of your body at different intervals). This is a therapy that I recommend for people who want to have tools and process their trauma without having to re-hash a timeline or go detail by detail with a therapist – or for someone who talk therapy just hasn’t helped much.

7.      IFS: Internal Family Systems – a family systems therapy that is also used with individuals in therapy to look at the different “parts” we all have within us that make us who we are and influence our behavior. For example, most clients have a “part of them” that wants change and a “part of them” that resists or is scared of change. IFS therapists work with these different parts in different ways to work towards client’s goals and self-integration.

8.      RO-DBT: Radically-Open Dialectical Behavior Therapy - this is a specialized therapy, that is derived from traditional DBT but geared more towards those that are over-controlled, think: perfectionist, Type-A people. This has been used successfully with those with eating disorders as well. RO-DBT is also a skills-based, structured therapy that teaches skills about emotional expression, social signaling, self-inquiry, personal effectiveness, boundaries, how to receive feedback, how to challenge rigidity in order to be more flexible, etc.

9.      SFBT: Solution-focused Brief Therapy – a strengths-based, post-modern approach that believes the client is the expert in the therapy room and the therapist is the guide to the client’s own wisdom about what has worked for them and what they want instead of the issues/problems they are experiencing now. Together, they build moments of “exceptions” to the problem and identify what success and solutions looks like for the client, sometimes without diving too deeply into the problem. “Brief” refers to length of treatment common for this type of therapy (~ less than 10 sessions, but not all SFBT providers limit their sessions to be this brief).

10.  TF-CBT: Trauma-focused Cognitive-Behavioral Therapy - this framework is therapy that guides the clinician and the client through trauma processing. Usually the therapy involves desensitizing oneself to one’s trauma story by sharing it with the clinician and reframing and reprocessing where necessary to work through an “old trauma story” and hopefully find a new story that helps the client integrate the events into their life while decreasing triggers and PTSD symptoms.

Questions to Ask Them (at first contact/consult):

1.      Do you take insurance/how much will this cost?

2.      What would a session with you look like?

3.      What experience do you have working with these issues/topics?

4.      How frequently will we meet/What determines the frequency of sessions?

5.      What are your specialties?

6.      What modalities do you use?

7.      What client do you work with best?

Questions to Ask Yourself (after first contact/consult):

1.      Did I feel comfortable talking to this person?

2.      Do I feel hopeful about working together?

3.      Did I feel heard and understood?

4.      Does it feel like a good fit for what I’m needing/wanting right now?

5.      Am I looking forward to my next session?

I hope you can use this cheat sheet to feel empowered in your search to find the a provider who is a good fit for what you are needing.

Trust yourself.

And if it turns out to not be such a good fit, you have the right to terminate treatment at any time! Remember, research shows it is the quality of the therapeutic relationship that determines overall therapeutic success.

Good luck out there! I’m cheering for you!

If you’re interested in scheduling a free consultation with one of Riverbank’s therapists, fill out the contact form here.

How to Get the Most Out of Therapy

Common questions I hear about therapy:

Where to start and how to know what you talk about?

In short, start anywhere! Talk about anything!

Most therapists will somewhat guide the first few sessions. They’ll likely ask what motivated you to start therapy, what your present concerns are, and go from there. I love to get a life timeline from new clients so I can get a sense of you in context of your whole life, while other therapists focus more on what’s happening in the present/near past.

One of my mottos in therapy is that “everything is everything” so anywhere you start will get you somewhere useful. Usually the most important thing will bubble up if you just start talking.

How do I open up if I’m not used to being vulnerable with people?

Therapy does require some vulnerability and openness. You’re going to have to talk about yourself. If this isn’t something you’re used to doing, that’s okay! There are some clients who come to therapy ready to talk and spend the whole session filled with words. Others are more reserved or more quiet in session. If this is you, your therapist will sense this and likely ask you more questions. You might also tell your therapist that you have a hard time opening up, and ask them to direct the process a little bit more until you become more comfortable. It can take time to build up the trust needed to be vulnerable and open with your therapist, and this is totally okay. Take your time, we have to earn your trust.

What if I have a challenge between sessions but feel fine on the day of my session?

This is so common! A few thoughts:

-bring up the challenge anyway. Often, it can be useful to explore an issue when it’s “cold” rather than “hot” because you have a different or clearer perspective.

-bring up something that you don’t usually get to talk about. Therapy isn’t always about day to day struggles, it can also be about processing the past, exploring an aspect of your identity, etc. So if you come into therapy on a good day, you and your therapist can brainstorm about things you’ve pinned in the past that might be useful to dig around. Sometimes these end up being the BEST sessions.

Other tips that will help you get the most out of the therapy process:

Do your homework! I almost always give something to my clients to do between sessions--whether it's reflect on something, journal about something, or try something new. The clients who get the most out of the process are the ones who actively do their homework. Remember--the therapy hour is only 1 of 168 hours in a week. If you want change to happen, you have to apply the therapy work in the other 167 hours!

Be honest and specific with your therapist. It can be difficult to work on an issue if we are constantly talking about it only a conceptual level. Bring in specific examples where this issue showed up, how you were feeling, what you were thinking about, what triggered that emotion, etc. As you build awareness in therapy, this will get easier. It can be helpful to make notes between sessions and come into your session with a few things you'd like to talk about.

Tell your therapist what is and isn't working. Give feedback! This process is FOR YOU, so if something isn't working, if you want to do more of something else, if you're upset at your therapist, say something! This feedback is hugely helpful for you and your therapist to make sure the process is tailored to you.

Take an experimental, curious attitude. Try something before you say "this won't work for me". See how it fits! If something doesn't work well for you, examine with your therapist what didn't work about it. Even when tools don't work, that's great information for the therapy process. Being specific about what you tried, when, and how it felt can help you and your therapist hone in on the tools that WILL work for you!

Be patient and kind with yourself. Shame gets in the way of each of the recommendations above. Give yourself credit for showing up for yourself, for taking care of yourself, and for doing what you can to make changes. Ask your therapist what changes they're seeing in you--often they might see things that you don't. Make time to give yourself kudos for doing the damn thing!

Want more? I answer these questions in more detail, and other questions on the podcast! Access the Toni Talks Therapy podcast anywhere you get your podcasts!

Online Counseling Tips for Clients and Therapists

Telehealth is a huge shift for most of us—clients and therapists alike. Here are som tips for you as a client during telehealth sessions:

• change your mindset: online therapy can be equally as helpful as in person sessions. It’s new, and might feel uncomfortable at first, but this doesn’t mean it won’t be useful to you.

• be as close to your internet router as possible to prevent connectivity issues

• find a private space with a closed door

• create a physical environment that feels safe and comfortable

• boundaries--share visually only what you want to share of your home, this can be a little or a lot. You might want your therapist to see your whole living room and meet your dog, or you might want to sit down in a nondescript corner to keep the boundaries more clear and separated. Up to you!

• close other open windows on your computer and put your phone away & on silent to minimize distraction

• put a post-it note over your face if it's distracting to see yourself

• talk with your therapist about what happens if you get disconnected

• know that it might feel different than in person, and that's okay

• get comfortable with silences, they are just like in office; you don't have to always fill space.

• bring up discomfort with the change, process with your therapist how it's impacting your experience

The tips for therapists are really similar, below are the ones that are additional or different:

• change your mindset: online therapy can be equally as helpful. Almost any therapy modality can be adapted to online sessions (I’m speaking from experience here—I’m a somatic therapist and online work for this can be challenging when I can’t see my client’s entire body, can’t feel their breath as I can in office, etc; but I have been able to find ways to adapt it to online. Anything is possible if we get creative).

• find a private space with a closed door, add a sound machine if you can, especially if you're at home

• create a physical environment that feels similar to your office. This can help with getting you into your procedural learning for “therapy session” and get into “therapist mode”. Honestly, I can’t do this if I’m in my PJs or sweatpants. I dress like I’m going to work (which is actually pretty casual), so that I feel as similar to in-person sessions as possible.

• boundaries--share visually only what you want to share of your home. It can be uncomfortable to bring our clients into our homes, even if virtually, because we work hard to “not bring the work home” with us. Figure out a way to set these physical or energetic boundaries with virtual sessions.

• call your clients' insurance to double check coverage. Most carriers have the same coverage for telehealth as in-person sessions, but some process the claims differently. Check with your clients’ carriers so that you can be clear with them about potential cost and coverage changes.

• make sure your clients know what happens if you get disconnected. My rule of thumb is to call them on their cell phone, troubleshoot video issues, and if we can’t resolve them we finish the session by phone. Talk with your clients about what they would prefer if you get disconnected.

• tell your client about what might feel different about online sessions, check in with them about all of the above. If you’re new to doing online sessions, be transparent about the fact that you’re adjusting to this new thing together.

• be ready to process attachment and relationship changes that might come up in session. Clients might feel less connected to you, less seen by you, or on the other side, they might feel TOO see by being on video, or might feel their space being intruded upon. Be mindful of this, name it if it comes up, and be ready to process it.

• give yourself longer breaks between sessions to move your body and to look away from a screen. Please take care of yourself! I’m finding that doing online sessions is more exhausting and my eyes get really tired. Time away from my screen and moving my body, along with longer breaks between sessions and less clients per day (when possible) has been really helpful.

I’d love to hear from you—either as a client or a therapist—how are you adjusting to online sessions? How is it feeling? What did I miss?

Interested in teletherapy during the pandemic? We are taking on new clients! Head to our contact page to reach out, let us know what you’re looking for, and we’ll fit you with one of our fantastic therapists.

How To Start Therapy

Have you been wanting to start therapy, but aren’t sure how to get started? It can unfortunately be a daunting and anxiety-provoking process. I’m here with some tips to make the process a little bit more clear, so you can go into it empowered!

Step 1: Begin your search.

The easiest way to find a therapist is to do a search online. Go to psychologytoday.com and search for your area (ex: “Seattle, WA” or your zip code “98107”). You can filter by specialty area, therapy style and more.

You can also call your insurance and get their provider list for your area. This is great if you know you need to see someone who is in-network with your insurance. If you go this route, I would still recommend searching through those therapists’ profiles online to see who resonates with you. This way you don’t end up with a random person just because they take your insurance, but actually end up with a therapist who works for what you’re looking for!

Another great option to find a therapist is to ask your doctors, friends or coworkers if they have any recommendations. And, if you happen to be lucky enough to have a therapist as a friend ;) you could ask them for referrals as well. Trust me, I’m giving referrals to friends all the dang time! I love doing it.

You can check out Riverbank’s clinicians profiles as well! Dana and Emily are both accepting new clients.

Step 2: You’ve narrowed down your list to a few therapists that you feel drawn to…now it’s time to schedule consultations.

Most therapists offer a free 20-30 minute consultation either by phone or in office. This helps both you and the therapist decide if it will be a good fit. If it is, great! You’ll schedule an intake session and get going! If it's not a good fit, you can ask that therapist for referrals and they can help point you in a different direction.

When you’re reaching out to schedule consultations, know that a lot of therapists won’t have openings for new clients. This can be frustrating, but I want to acknowledge that it’s a part of the process. Usually when my schedule is full, I’ll still offer referrals to new clients who reach out. I’d encourage you to ask for this, especially if it’s a therapist you really wanted to work for. Likely, the people they know and like who they refer you to are clinicians that are pretty similar to them :)

Step 3: Okay, so you’ve got a consultation scheduled! What the heck do you say?!

Share a bit about why you’re seeking counseling. Keep in mind that you only have 20 minutes, so this is not the time for your entire life story (that comes later!). This is the Cliffsnotes version. Ex: “I’ve been struggling with depression and anxiety since my teen years, and recently it’s gotten worse since I’ve accepted a new job in a new city. I’d like to work on some coping skills for anxiety, and especially around making new friends in Seattle.” Your therapist will likely ask a few more questions about your life and why you’re coming to therapy, but something brief is good for now!

The consultation meeting is a perfect time to ask questions of the therapist, which will help YOU determine if they’re a good fit for you. As a therapist, I don’t want this process to be hidden behind the curtain--I strive for transparency and clarity, because that will make the process that much easier for the both of us! I love these kinds of questions from potential new clients (and current clients for that matter!)

Questions to ask:

-What are your areas of specialty? (Depression, anxiety, trauma, body image, etc).

-What theories do you work from in therapy (CBT, DBT, ACT, somatic, etc.) Ask them to explain what these mean for therapy and how they implement them.

-How often will we meet, and what is your schedule?

-What will a typical session look like?

-What are your fees? Are you covered by my insurance? If not, will you submit out of network bills or provide me a superbill?

Step 4: Check in with yourself.

The most important questions you can ask after a consultation are to yourself. Do I like this person? Do I feel comfortable with them? Do I feel heard and understood? Most of all, get a feel for the therapist's personality and energy. If it resonates with you, they're probably a good fit. If you feel uncomfortable (more than expected when going to therapy for the first time), then it's probably a signal that it's not a great fit.

The therapist will not be offended if you choose not to work with them! Sometimes it takes several consultations to find the right fit. Know that it’s a process of shopping around, and be patient with it. You have the right to choose your provider, and therapy will work best when you work with someone who is a good fit.

After a consultation, you’ll schedule an intake appointment with the therapist you’ve chosen to work with. Prior to or at your intake session, you’ll sign some paperwork with your counselor and then you’ll get started!

Going to therapy is fantastic and will help you grow in big ways, so take the time up front to find a provider that works for you!

Want to schedule a consultation with one of our therapists? Email us to schedule a consultation here!