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Out-of-Network Billing – Ask a Biller #5

In Ask A Biller Episode 6, Dylan and Maggie answer all of your questions about billing insurance when you’re out-of-network. Plus we have a special guest this week: Better joins us to share tips on how Superbills can help your clients get reimbursed!

See the full transcript here (scroll to read):

DYLAN: Hi and welcome to this very special and highly anticipated episode 6 of Ask A Biller. This is all about how to navigate insurance as an out of network provider. As always, I’m Dylan from your favorite SimplePractice billing service, SmartBilling Pro

MAGGIE: And I’m Maggie, an insurance specialist here at SimplePractice. We’re super excited about this episode– not just because we get endless customer questions about billing out of network, but because we have a really awesome guest segment that was put together by our friends at Better– a really awesome company that we partner with. They help your clients get reimbursed at no cost to you!

DYLAN: In today’s video we will cover the following topics: how out of network benefits work, courtesy billing, balance billing, superbills, and lastly we will address the questions that you’ve been sending us for the last 5 months.

MAGGIE: So let’s get started by understanding how out of network benefits work for your clients. The first thing to understand is that not all plans have out of network coverage. If your client’s plan is an HMO or EPO, they do not have out of network coverage and will not be reimbursed for your services

DYLAN: Plans that will likely have some kind of out of network benefits are PPOs and POS’ plans– but always be sure to check with the payer first. Next, out of network benefits are usually totally separate from in-network coverage. This means that if your client has a deductible with their contracted plan; services that they pay for that are out of network will not go towards the in-network deductible. If the plan that they’re on says they have a deductible that needs to be met before the payer will reimburse any services that are out of network, it’s usually separate from the one that they’re paying for in-network. Again, that means there’s two entirely separate levels of coverage.

MAGGIE: You may come to find that a lot of out of network coverage is sparse. Additionally, payers will not reimburse clients based on your private session fee, reimbursement is based upon what it called an allowed amount– the value of the service given by the payer based on what they deem appropriate to charge.

DYAN: That means that your client’s coverage could say that for out of network services, they’ll be reimbursed at 50% and let’s say your session fee is $100–naturally you would think that the client would be reimbursed $50 for this service, however that is not the case. The payer will reimburse off of their allowed amount, in this example they believe the service to be valued at $80 so they will reimburse the client $40.

MAGGIE: Many clients might not understand the intricacies of out of network coverage so it’s important to be knowledgeable and set realistic expectations regarding reimbursements.

DYLAN: That being said, there are a few options for how you, an out of network provider, can choose to navigate insurance. The first option we’re going to talk about is courtesy billing

MAGGIE: Courtesy billing is when you’re not contracted with an insurance payer, but opt to file claims on your clients’ behalf. This is a good option to relieve the stress some of your clients might face trying to understand how to submit clinical information to a payer

DYLAN: Many payers will allow you to courtesy bill electronically, but you will want to call the payer first because there may be some required paperwork to submit before they’ll start accepting your claims.

MAGGIE: In this scenario, most providers will charge their client the full session fee up front or will make other arrangements to determine what the client is responsible for, and filing their claims really is just a courtesy. Payers will usually reimburse the clients directly. Because you don’t have any kind of contractual obligation to this payer, there’s no expectation that they will send payments to you.

DYLAN: To make sure that reimbursements are sent to your client, you will need to check box 27 on the claim form– to not accept assignment AKA send the money to the policy holder, not you

MAGGIE: Another thing to keep in mind is that the payer is usually going to send reimbursements to the plan’s policy holder, usually in the form of a check made out to in their name, regardless of who the patient is, unless arrangements are made ahead of time. This is important to consider if you’re working with spouses going through a divorce, or children that are covered under a parent’s plan that they don’t live with

DYLAN: Payers are reluctant to send payments to anyone other than the person who they’re contracted with, and in this scenario, the policyholder, OR, the person that signed up for the coverage is the only one that they have a contract with.

SmartBilling Pro tip: The best way to handle this is to collect your full free up front from the client and let them keep and cash the reimbursement check. Expecting them to bring in and sign over the checks to you gets difficult and confusing fast.

MAGGIE: The next term that we’re going to go over is Balance Billing. This refers to billing your client the difference between your full session rate and the payer’s allowed amount. Let’s say your session fee is $100, the payer deems the session worth $80 and that the client owes $40. Charging your client the $60 difference is an example of balance billing. You can only balance bill if you are out network with the client’s plan. Payers on insurance panels are bound by contract to only charge the agreed upon amount.

DYLAN: Next up, our partners at Better are going to tell you everything that you need to know about SuperBills otherwise known as: insurance reimbursement forms


MAGGIE: Awesome, thank you to the team at Better for stepping in to explain SuperBills! The last thing we’re going to do is cover some questions from our community. These are question that we’ve collected over time and saved specifically for this episode

Q: How can a counselor in private practice file for out of network benefits/payments? How can the private practice counselor know how much to charge for the deductible in an out-of -network client. – Tracey

DYLAN: Hi Tracey, yes any licensed counselor in private practice can at least attempt to file for out of network claims. That doesn’t guarantee that the services will be eligible for reimbursement. You can verify the client’s coverage ahead of time, but you may run into issues calling the payer for this information. Payers are less inclined to share benefit information with providers that aren’t on their panel so your safest bet is to charge your client your full session fee or whatever you’re comfortable charging per session, and waiting for the first claim to be adjudicated to determine how their plan processes the service.

Q:Can I use databases such as Navinet or Availity to verify benefits if I am out-of-network? – Laurey

MAGGIE: Good question, Laurey. The answer is yes, you can use navinet or availity if you’re set up with either. However, we recommend being cautious when giving these benefits to clients. Sometimes the out of network benefits aren’t super comprehensive.

Q: If you’re submitting a claim as a courtesy for an out-of-network client in SP, how do you indicate that the insurance claim was paid, etc. in the claim list? – Anna

MAGGIE: Currently the SimplePractice insurance payment page is set up to account with in-network insurance payments in mind, meaning that some part of your full session fee is discounted, or ‘written-off’ so claim statuses will update to paid automatically when you enter a payment from the insurance and account for a write off and client payment. If you’re courtesy filing and you’re not writing anything off, you’ll want to have your client’s billing type set to self-pay, and charge them the full rate for the session. In this scenario those payments should be going to the client so you shouldn’t have an insurance payment to record, therefore the claim status won’t update to paid, but the client also won’t be accumulating an insurance balance.

Q: Looking for some insight. New patient has Florida Blue, which I am OON with. Client will self pay, but am willing to file the claims and reject assignment for her through SP. Do I still have to enroll… -Susan

DYLAN: Hi Susan, the answer to your question is no, you don’t have to file an enrollment through SP, and that’s because Florida Blue Cross BLue Shield doesn’t require enrollment for claim filing. Enrollment requirements vary by payer. Keep in mind that some payers require that you submit some documents to them before they will accept your out of network claims electronically. This process is handled outside of SimplePractice. For more information on that subject, check out Episode 1 of Ask A BIller where we talk all about enrollments.

Q: Is there a way to opt out of electronic payment reports for an insurance company? The reports do not take into consideration that I am out-of-network and they mess up my book keeping! -Jennie

MAGGIE: That’s a good point, Jennie. And yes, you can opt out of automatic payment reports. Automatic payment reports are especially beneficial for in-network providers that bill exactly how the insurance processes their claims, but if you’re out of network and setting unique session rates and write offs that differ from what the payer says, they may not be helpful for you. If you’re currently receiving payment reports that you don’t want, please send in a support request through our HelpCenter and one of our insurance specialists will help you get that squared away.

DYLAN: That’s it for today. Thanks so much for tuning into this episode of Ask A Biller, and thanks again to the folks at Better for contributing an awesome segment this month. We’ll see you all again on July 19th when we will be hosting a live Q&A. Remember, you can get updates and see all the past episodes on our youtube channel, so make sure you subscribe!

MAGGIE: And remember, if you have questions that are specific to your SimplePractice account, take a look at our HelpCenter at support.simplepractice.com and browse through some of the live support classes that we offer. Until next time,

MAGGIE, DYLAN: Keep it Simple!

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