How to handle out-of-network billing: a guide for therapists

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Out-of-network billing can be the right choice for therapists looking to take charge of their private practices. But let’s face it—navigating payments and insurance claims can get a little overwhelming. From piles of paperwork to decoding insurance jargon, it’s not always easy to make the process smooth for you or your patients.

The good news? With the right tools and some simple strategies, out-of-network billing doesn’t have to be stressful. This guide can help you break it all down, offering practical tips to make billing easier and ensure a seamless experience for you and the people you care for.

Understanding out-of-network billing

What does it mean to be out-of-network? An out-of-network provider is not affiliated with a patient’s insurance panel. This means you are not bound by contractually established reimbursement rates set by insurance companies and are free to set your service fees. Patients pay directly for sessions and may submit reimbursement claims to their insurers, assuming their insurance plans include out-of-network benefits.

Out-of-network billing often provides these key advantages for therapists:

Set your own rules: enjoy the freedom to determine your rates and control how your practice operates.
Avoid payment restrictions: increase your earnings by bypassing the reduced payments and fee schedules of insurance contracts.
Minimize administrative work: eliminate the hassle of insurance pre-authorizations and complex backend billing tasks.

However, the reimbursement process requires therapist participation in providing accurate billing documentation, which patients use to claim a portion of the fees paid.

Steps in the out-of-network billing process

To keep things running smoothly, it’s important to understand the key steps in out-of-network billing for therapists.

Step 1: Verify patient insurance benefits

The first step is determining whether a patient’s insurance includes out-of-network benefits. This process often involves helping patients verify the following:

The percentage of reimbursement (usually ranging between 40-80% depending on the plan).
The deductible amount and how much of it has been met.
The plan’s annual out-of-pocket maximums.

Tools that automatically verify out-of-network benefits simplify this process. Using these solutions can help you provide patients with detailed information about their potential reimbursement before their first session.

Tip: Have an open conversation with patients about what to expect when it comes to reimbursement amounts and timelines. Being clear upfront helps avoid confusion and builds trust along the way.

Step 2: Provide a superbill

A superbill is an essential tool for reimbursing out-of-network expenses. A comprehensive superbill is a detailed invoice that contains all the necessary information required for your patients to submit claims to their insurance providers.

Key information to include on your superbill:

Patient’s name, address, and date of birth.
Therapist’s details (name, NPI number, tax ID, licensing information, and office address).
Session details (dates of service, CPT codes for services provided, and applicable fees).
Diagnosis code (ICD-10 code, if applicable).
Statement that the patient has paid in full for services.

Tools to create superbills: Many electronic health record (EHR) systems offer features to easily generate superbills with just a few clicks, streamlining the process and reducing administrative workload.

Step 3: Support patients in submitting claims

Once the superbill is provided patients can upload the document directly to their insurance provider’s member portal or mail it in. Some therapists offer additional services, such as submitting claims on a patient’s behalf using billing software or third-party solutions. This reduces the workload for patients but requires additional administrative time for therapists.

Helping patients understand why claims might get rejected—like missing info or going over coverage limits—can make a big difference. By tackling these issues upfront, we can make the reimbursement process smoother and quicker for everyone.

Step 4: Utilize third-party solutions

There are platforms out there designed to make life easier for both therapists and their patients when it comes to dealing with insurance. They handle things like verifying benefits, creating claims, and even submitting them on patients’ behalf.

For therapists looking to cut down on admin stress, tools like these can simplify your workflow and create a smoother experience for your patients, helping them feel supported every step of the way.

Tools to simplify out-of-network billing

Out-of-network billing can be a real headache for both providers and patients. Dealing with different insurance rules, surprise denials, and unclear reimbursement rates creates confusion and delays. Patients are often left unsure about their costs, while providers face the time-consuming hassle of managing claims. It’s a frustrating process that highlights the need for better communication and systems to make things easier for everyone.

EHR platforms: digital tools that help streamline documentation, appointment scheduling, and superbill generation for therapy practices.
Benefits verification platforms: systems that offer real-time insurance benefit verifications, enabling patients to make informed decisions about accessing therapy.
Billing payors directly: solutions that allow seamless insurance billing and help manage patient invoices and payments from a centralized system.

With these tools, therapists can save time, avoid headaches, and make it easier to get successful claims for their patients.

Final thoughts

Out-of-network billing can be a great option for therapists looking for more freedom and financial flexibility in their practice. Sure, it takes some organization and clear communication, but the good news is that tools like EHR software and third-party services can make it so much easier. With the right systems in place, out-of-network billing can help make therapy more accessible for patients while ensuring you’re fairly compensated for the important work you do.