3 Tips for Simplifying Out of Network Therapy Billing

There are many reasons to consider leaving your insurance panel for greener, and freer, out of network pastures. Though it can be comfortable to stay in-network, you might see stagnation in your private therapy practice’s growth. Competition might become more fierce, and margins might start to look a little thin. While operating in-network can be advantageous, it undeniably carries some drawbacks, most of which are financial. When it comes to how to be a successful therapist, thinking outside the insurance network may be the solution for providers who feel this pressure.

Unfortunately, both paneled and out of network providers have a fair amount of paperwork to complete. So, if you decide to take the leap and resign from your insurance panel, you’ll want to know the answer to the most important question: how will you get paid?

How does out of network billing work?

Broadly speaking, clinicians who are out of network have not signed a contract with an insurance company and do not have to abide by a contracted rate. Though, it’s important to note that these providers can still be subject to insurance audits for medical necessity and are still considered a HIPAA-covered entity. Some patient plans may have partial out of network benefits, and some have none at all. Usually, plans with very high deductibles will not reimburse out of network services until the deductible is met, which can be difficult for some patients to meet. Because every insurance plan is slightly different, never guarantee a patient that they will receive insurance reimbursement for seeing you out of network.

Tactically, the biggest difference between in-network and out of network billing is how a claims form is completed. When you are in-network, Boxes 13 and 27 are always marked ‘YES’ because you want the insurance company to send the payment to you, the clinician. When you are out of network you have the option of sending the payment to the clinician or to the client. If the client would pay you your full fee as an out of network provider, you would indicate this on your claim form and select ‘NO’ in boxes 13 and 27 so that the insurance company reimburses the client.

Another major difference is with government health care plans such as TRICARE and Medicare. In regard to how to become an out of network provider, TRICARE requires providers to apply to be out of network before being able to bill. Medicare has no out of network benefits, and you must be an eligible Medicare provider for claims to get accepted.

So, how do you appropriately bill your out of network patients as simply as possible for both you and the client?

Tip #1: Issue A Superbill

This is the option that most out of network clinicians use because this puts most of the work on the client. Think of a superbill as a detailed receipt of the client’s sessions. Though it is like a regular invoice or statement with very similar information that a claim form would have, it will look more client friendly.

Information on a superbill includes:

  • The client’s name, date of birth, address and insurance information (company, ID/Group etc.)
  • The clinician’s name, tax ID, NPI, office address
  • The dates the session took place (Dates of Service)
  • CPT codes used and the client’s diagnosis
  • The amount charged for the session and the amount the client paid
  • Whom payments should go to (client)

The client would then use the information provided on the superbill to submit the claim to their insurance provider to receive reimbursement. They can usually do this on the insurance company’s member website or portal.

Tip #2: Submit on Client’s Behalf

Though it takes a little more administrative time on your end, submitting your clients’ claims on their behalf is a nice service to offer, and there is therapy practice management software that can simplify the process. In this case, you would submit billing for them, not accept assignment (payment), and have the insurance provider reimburse the client. Billing an insurance company as an out of network provider is very similar to billing when you are in-network. There are a few differences.

This puts a ‘NO’ in box 27 on the claim form to indicate that you want the insurance company to reimburse the client and not the clinician. This also unchecks box 13 on the claim form. Think of these boxes as saying “Should we send the payment to the clinician?” Yes or No.

Tip #3: Offer A Reasonable Rate

A third way you could simplify the out of network billing process is to offer a reasonable rate for out of pocket payments. Think of it like a comparable charge to in-network rates. Because insurance companies take a portion of your payment, you end up making less than your full rate when you’re paneled. Without insurance involvement, you can technically charge less, but still make more.

However, when you are creating a superbill for a client, make sure to list your higher, full rate.

Established to protect insurance companies from paying at the mercy of whatever health care providers charged, insurance companies take an average of each CPT code billed by providers with the same licensure level in your region to determine UCR. This is why you should bill your full fee to insurance companies.

Even if you are out of network with an insurance company, you should still verify the client’s out of network benefits. This way the client knows if they have a deductible to meet (most out of network insurance benefits have higher deductibles) before they will get insurance reimbursement. Advekit, a therapy matching service,  makes sure the client understands their insurance benefits before you even have a session, so there are no surprises for client or provider, and it allows our therapists to get paid immediately, instead of waiting on insurance.

Learn more about becoming an out of network therapist with Advekit today.


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