Reimbursement basics

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Overview

Out-of-network reimbursement is money an insurance carrier may pay back after it processes a claim. Thrizer helps submit and track supported claims, estimate reimbursement from available benefit information, and send reimbursements based on the payment type being used. The insurance carrier makes the final decision on whether the claim is approved, whether money is reimbursed, how much is paid, and when the claim is processed. Any reimbursement amount shown before insurance finishes processing the claim is an estimate, not a guarantee.

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How reimbursement usually works

Reimbursement usually depends on four things:

• what the clinician charges
• what insurance recognizes for the service
• whether the client has met their deductible
• what share of the cost the client owes after the deductible is met

The most important thing to know is this: Insurance usually calculates reimbursement from the amount it recognizes for the service, not necessarily the clinician’s full session fee.

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Why the clinician’s fee and insurance amount can be different

The clinician’s fee is the full session rate. Insurance may recognize a different amount for the same service. That recognized amount is often called the allowed amount. For example:

• the clinician charges $200
• insurance recognizes $140 for that service
• reimbursement is usually calculated from $140, not $200

The difference between the clinician’s fee and the amount insurance recognizes may remain the client’s responsibility.

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How the deductible affects reimbursement

A deductible is the amount a client must pay before insurance starts reimbursing eligible services. If the deductible has not been met, a claim can be approved and still result in $0 reimbursement. That does not always mean the claim failed. It may mean insurance accepted the claim and counted the recognized amount toward the client’s deductible instead of paying money back. In plain English:

• approved can mean paid
• approved can also mean applied to deductible
• denied means insurance did not approve the claim for reimbursement or deductible credit

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How coinsurance affects reimbursement

Coinsurance is the client’s share after the deductible has been met. For example, if the deductible has been met, insurance recognizes $140 for a session, and the client has 20% coinsurance:

• the client’s share of the recognized amount is $28
• insurance may reimburse the remaining $112
• the client may still be responsible for any difference between the clinician’s fee and the amount insurance recognizes

This example assumes the claim is approved and no other plan rules apply.

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Common claim outcomes

A processed claim usually falls into one of these categories. The “applied to deductible” outcome is one of the most common sources of confusion. The claim may be valid and accepted, but it does not produce a payment yet.

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Why an estimate can change

Before insurance processes a claim, Thrizer may estimate reimbursement using the information available at that time. That information may include deductible status, coinsurance, plan details, and an estimated amount insurance may recognize for the service. The final result can change because insurance makes the final decision after reviewing the claim. Common reasons estimates change include:

• insurance recognizes a different amount for the session
• the claim goes toward deductible instead of reimbursement
• deductible information changes before the claim is processed
• the benefit check returned incomplete information
• insurance denies the claim
• the first processed claim gives new information about how the plan actually reimburses

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What benefit checks can tell you

A benefit check helps Thrizer estimate out-of-network benefits using information available from the insurance plan. Benefit checks may help estimate:

• deductible status
• deductible remaining
• coinsurance
• whether out-of-network benefit information is available
• whether manual verification may be needed

Benefit checks are useful, but they are not final claim decisions. The insurance carrier still determines the final result after the claim is processed.

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What Thrizer does

Thrizer helps with:

• estimating reimbursement from available benefit information
• submitting supported out-of-network claims
• tracking claim status
• sending reimbursement based on the payment type
• updating future estimates when actual claim information becomes available

Thrizer does not decide whether insurance approves the claim or how much insurance pays.

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What insurance determines

The insurance carrier determines:

• whether the claim is approved or denied
• what amount it recognizes for the service
• whether the claim is reimbursed or applied to deductible
• how much reimbursement is paid
• when the claim is processed

This is why reimbursement estimates can be helpful but cannot be guaranteed.

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What this means for clients

Use reimbursement estimates as a planning tool. The final amount may be higher, lower, or $0. A $0 reimbursement does not always mean something went wrong. It may mean the claim was applied to the deductible. For OON Pay, you pay the full session fee upfront. If insurance reimburses the claim, reimbursement is sent back to you through Thrizer. Some insurers send reimbursement directly to you instead of through Thrizer, for example by mailing a paper check to the address on file. The insurer chooses the delivery method, and Thrizer cannot control it. This does not change your upfront payment, your clinician’s payout, or how Thrizer submits the claim. When reimbursement is sent directly to you this way, the 1% OON Pay fee is not charged. For Thrizer Pay, you pay an estimated responsibility upfront. Thrizer advances part of the session fee to your clinician, so reimbursement for that claim goes to Thrizer. If the insurer’s final result differs from the estimate, your final responsibility may change.

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BCBS reimbursement

BCBS plans do not permit third-party entities like Thrizer to receive reimbursement on a client’s behalf. Thrizer Pay and OON Pay direct deposit are therefore not available for BCBS umbrella plans. Clients receive reimbursement by paper check directly from their insurance company.

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Which plans are affected

This applies to all plans under the BCBS umbrella, including plans administered by Elevance Health. Known examples include Anthem BCBS, Carelon, NYSHIP (administered by Carelon), Wellpoint, Empire BCBS, Highmark BCBS, Horizon BCBS, BCBS of Massachusetts, BCBS of Texas, BCBS of Illinois, and other regional BCBS plans. These examples are not exhaustive. Benefit-check results show the reimbursement methods for the client’s specific plan.

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What changes for clients

• Clinicians charge as usual, and Thrizer still submits eligible claims automatically after each OON Pay charge.
• Clients use OON Pay and pay the clinician’s full session rate upfront.
• Clients previously on Thrizer Pay move to OON Pay for future sessions. Existing completed charges are not relabeled.
• Clients previously using OON Pay direct deposit receive reimbursement by paper check instead.
• Reimbursement often arrives in about 6 weeks, but the insurer controls claim approval, the reimbursement amount, check delivery, and timing. The 6-week estimate is not a guarantee.
• The insurer mails the check using the address in its own records. Clients should confirm or update their mailing address directly with the insurer. Thrizer cannot redirect a payer-issued check.

Practices: complete provider registration with each required Blue plan.

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What this means for clinicians

Do not present reimbursement estimates as guaranteed client savings. A client’s final reimbursement can differ from the estimate even when you submit the claim correctly. Thrizer helps create a clearer claims and reimbursement process, but insurance remains responsible for final claim decisions.

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