Insurance payment examples

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Short answer

These examples show how out-of-network insurance payments can work in common Thrizer situations. They use simple numbers to explain the relationship between:

• the clinician’s session fee
• the insurance allowed amount
• the client’s deductible
• coinsurance
• reimbursement
• OON Pay
• Thrizer Pay

These examples are educational only. They do not guarantee what any specific insurance plan will cover, approve, apply to a deductible, or reimburse. Insurance determines the final allowed amount, deductible application, reimbursement amount, claim outcome, and claim timing.

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Before you read the examples

A few terms matter most. Session fee is the clinician’s full charge for the session. Allowed amount is the amount the insurance plan uses to calculate reimbursement. Insurance reimbursement is based on the allowed amount, not necessarily the full session fee. Deductible is the amount a client must pay before insurance begins reimbursing eligible services. Coinsurance is the client’s share of the allowed amount after the deductible has been met. Client responsibility, in these examples, means the amount the client is responsible for after any reimbursement is considered. This may include deductible application, coinsurance, and any difference between the session fee and the allowed amount.

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Example 1: The deductible has not been met

A client has a $200 session. For this example:

• Session fee: $200
• Insurance allowed amount: $120
• Deductible remaining: $500
• Claim status: Approved

Because the client still has more deductible remaining than the allowed amount, the insurer may apply the $120 allowed amount toward the deductible. In this example:

• Insurance reimbursement: $0
• Amount applied to deductible: $120
• Client responsibility: $200

What this means: an approved claim can still result in $0 reimbursement when the client’s deductible has not been met.

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Example 2: The deductible is partly met during the claim

A client has a $200 session. For this example:

• Session fee: $200
• Insurance allowed amount: $120
• Deductible remaining: $50
• Client coinsurance after deductible: 20%
• Insurer share after deductible: 80%
• Claim status: Approved

The first $50 of the allowed amount is applied to the remaining deductible. That leaves$70 of the allowed amount after the deductible is met. The insurer then reimburses 80% of the remaining $70. In this example:

• Amount applied to deductible: $50
• Remaining allowed amount after deductible: $70
• Insurance reimbursement: $56
• Client responsibility: $144

What this means: a claim can produce partial reimbursement when part of the allowed amount goes to the deductible and the rest is reimbursed based on coinsurance.

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Example 3: The deductible has already been met

A client has a $200 session. For this example:

• Session fee: $200
• Insurance allowed amount: $120
• Deductible remaining: $0
• Client coinsurance: 20%
• Insurer share: 80%
• Claim status: Approved

Because the deductible has already been met, reimbursement is based on the allowed amount and coinsurance. In this example:

• Insurance reimbursement: $96
• Client responsibility: $104

What this means: even after the deductible is met, the client may still be responsible for part of the session fee. That can include the client’s coinsurance and any difference between the session fee and the allowed amount.

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Example 4: The session fee is lower than the allowed amount

A client has a $100 session. For this example:

• Session fee: $100
• Insurance allowed amount: $120
• Deductible remaining: $0
• Client coinsurance: 20%
• Insurer share: 80%
• Claim status: Approved

When the session fee is lower than the allowed amount, reimbursement is based on the lower amount. In this example:

• Effective amount used for reimbursement: $100
• Insurance reimbursement: $80
• Client responsibility: $20

What this means: insurance does not reimburse more than the amount charged for the session.

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Example 5: OON Pay after the deductible has been met

A client uses OON Pay for a $200 session. For this example:

• Session fee: $200
• Assumed insurance reimbursement: $96
• OON Pay client fee: 1% of the session fee
• Claim status: Approved
• Reimbursement amount: $96

With OON Pay, the client pays the full session fee upfront. Thrizer submits the claim automatically after the clinician creates the charge and the payment is successfully processed. If the insurer reimburses the claim, reimbursement is sent to the client. In this example:

• Client pays upfront: $200
• Insurance reimbursement: $96
• OON Pay fee: $2
• Net reimbursement sent to client: $94

What this means: with OON Pay, the client pays first and waits for reimbursement. The OON Pay fee is deducted from the reimbursement only when there is reimbursement.

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Example 6: OON Pay before the deductible has been met

A client uses OON Pay for a $200 session. For this example:

• Session fee: $200
• Insurance allowed amount: $120
• Deductible remaining: $500
• Claim status: Approved
• Reimbursement amount: $0

The client pays the full session fee upfront. The insurer approves the claim, but the allowed amount is applied to the client’s deductible instead of being reimbursed. In this example:

• Client pays upfront: $200
• Insurance reimbursement: $0
• Amount applied to deductible: $120
• OON Pay fee: $0

What this means: before the deductible is met, OON Pay can still include claim submission and tracking, but the client may not receive reimbursement.

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Example 7: Thrizer Pay when available

A client uses Thrizer Pay for a $200 session. This example assumes Thrizer Pay is available for the client. For this example:

• Session fee: $200
• Estimated client responsibility: $104
• Thrizer Pay fee: 5% of the session fee
• Estimated insurance reimbursement: $96
• Claim status: Approved

With Thrizer Pay, the client pays the estimated responsibility plus the Thrizer Pay fee at the time of service. Thrizer advances the remaining portion of the clinician’s session fee. Insurance reimbursement is routed to Thrizer. In this example:

• Estimated client responsibility: $104
• Thrizer Pay fee: $10
• Client pays upfront: $114
• Estimated amount advanced by Thrizer: $96
• Insurance reimbursement route: Insurance → Thrizer

What this means: with Thrizer Pay, the client does not pay the full session fee upfront. The final insurer outcome may still differ from the estimate, and that difference may result in an additional client charge or a refund.

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Example 8: The claim is denied

A client has a $200 session. For this example:

• Session fee: $200
• Claim status: Denied

When a claim is denied, there is no reimbursement and no deductible credit from that claim. In this example:

• Insurance reimbursement: $0
• Amount applied to deductible: $0

What this means: a denied claim is different from an approved claim that is applied to the deductible. An approved claim may still affect the deductible even if no money is reimbursed. A denied claim does not create reimbursement or deductible application.

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Why estimates can differ from the final result

Before a claim is processed, allowed amounts and reimbursement are based on available information. After the insurer processes the claim, the insurer determines the final allowed amount, deductible application, reimbursement amount, and claim outcome. Estimates may differ from the final result because:

• the allowed amount changes after the insurer processes the claim
• deductible information changes
• the insurer approves or denies the claim
• the insurer applies the claim to the deductible instead of reimbursing money

This is why estimated reimbursement and estimated out-of-pocket responsibility should be treated as guidance, not a guarantee.

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