Here are some tips to ease out of network billing confusion:

What/Who is Out Of Network?

• Clinicians who have not signed a contract with an insurance company and do not have to abide by a contracted rate.
• Can still be subject to insurance audits for medical necessity and are still considered a HIPAA-covered entity.
• Some plans may not have out of network benefits at all.
• Never guarantee a client that they will get reimbursed for seeing you out of network.
  • Usually, OON has very high deductibles which means the client (or you) would not get reimbursed until the deductible is met.

Options with OON billing:

• Charge client your full fee and give them a superbill to submit to their insurance company (Recommended!)
• Submit OON billing for them, do not accept assignment (payment), and have the insurance company reimburse the client
  • Depending on the client’s OON benefits
  • Check ‘No’ in Box 27
• Submit OON billing for them and accept assignment, charge client the difference between what insurance reimburses you and your full fee (balance billing)
  • Or go off of what the OON benefits are and do not balance bill—your choice

Superbill

• Itemized bill given to clients to submit to their insurance company for payment
• Can only do this if you are OON
• Has the same information that is on a claim form including:
  • Client’s demographic information
    • Insurance information, date of birth, address
  • Your EIN/NPI/License Number
  • The client’s diagnosis
  • CPT code and description
  • What you are charging insurance and what the client paid you

Usual Customary and Reasonable Rate

• Think of it like an unofficial out of network rate (without a contract)
• Established to protect insurance companies from paying at the mercy of whatever 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.
• Works like a contracted rate, but you can balance bill
• Example A:
  • Client has an OON deductible of $2,000 and the UCR is $100
  • You bill the client and the insurance company $150
  • The insurance company only applies $100 towards the deductible, but you can charge the client higher than the UCR due to not being in-network.
    • This is called ‘balance billing’ and is acceptable to do due to being OON and not having a contract with the insurance company. This is a contract violation if in-network as you have to collect your contracted rate and cannot balance bill.
• Example B:
  • Client has met their OON deductible and insurance is paying 80% co-insurance, UCR is $100
  • You bill the client and give the client a superbill with a $150 charge on it
  • The insurance company reimburses the client $80 (based off of the UCR and not what you billed the client).