Out of Network Billing Breakdown

“You’re getting lots of calls from clients with ABC insurance, but you do not want to become in-network, nor do you want to turn these clients away.”

Here are three options that help you bill out-of-network while also putting your clients at ease.

Option 1: Charge your client your full fee and then give them a “superbill”.

They then file the claim to get reimbursed by their insurance company.

This is the option that most out of network clinicians use because this puts most of the work on the client (whether this is good or bad is for your decide).

Think of a superbill as a detailed receipt of the client’s session. It is not just a regular invoice or statement, it has very similar information that a claim form would have, except it is 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
• Who payments should go to (client in this case)

Sounds similar to an actual claim form, right?

The client would then use the information provided on the superbill to submit the claim to their insurance company to get reimbursed. They can usually do this on the insurance company’s member website or portal. There are also apps that act as ‘out of network billers’ of sorts. Reimbursify is a popular one.

Option 2: Submit an out-of-network claim on the client’s behalf, do not accept assignment (payment), and have the insurance company reimburse the client.

This is the option I prefer because I like to offer a complete billing service for my clients regardless of their insurance and it really does not take me much time at all.

Billing an insurance company as an out-of-network provider is very similar to billing when you are in-network. The main difference being that when you set up the client’s insurance you would make sure to select 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 isn’t fool-proof and sometimes the insurance company will still pay you because you submitted a claim. This can create a bit of a headache as you then need to void the check and have the insurance company issue it to the client or possibly deposit it then pay the client….it gets tricky!

Option 3: Submit OON billing for them and accept assignment, charge client the difference between what insurance reimburses you and your full fee (balance billing)

This is really playing nicely with out of network billing as you are essentially billing as you out if you were in-network. I would only do this route if a client has great out of network benefits which usually does not happen often and you already bill a lot of in-network claims. You will get paid according to the UCR (usual, customary and reasonable rate) and then can charge the client the rest to equal to your full fee. This is called balance billing and you can only do this out of network as you have no contracted rate you have to follow.

INSURANCE GURU PRO-TIP:

Even if you are out-of-network with an insurance company, I would 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 reimbursed by the insurance company. Some insurance companies (like UHC) require the client to call them and give permission for an out of network provider to verify benefits. Don’t ask me why….