Out-of-Network Billing for Group Practices: Where to Start
Out-of-network billing for group practices means submitting claims, or giving clients paperwork to submit, for care your clinicians deliver without a contract with the client’s health plan. In a group, every clinician can have a different network status with every plan, so the process needs written rules. This guide covers benefit checks, superbills versus direct claims, and single case agreements. For the solo version, start with our post on out-of-network billing for therapists.
What is out-of-network billing for group practices?
A clinician is Out-of-Network (OON) when they have no contract with the client’s plan. The plan pays based on the client’s out-of-network benefits, if the plan has any, and the practice sets its own fee. Network status belongs to each clinician and each plan, so a group can be in network for one plan and out for another. Our page on credentialed and noncredentialed status explains the difference.
Verify out-of-network benefits before the first visit
Check benefits for every new client. Out-of-network coverage varies by plan, and a missed detail leaves a client with a balance and your practice with an unpaid claim. Follow the checklist in our guide to insurance verification for therapists and add these out-of-network questions:
- Does the plan have out-of-network mental health benefits for the clinician’s license type?
- Is there a separate out-of-network deductible, and how much is met?
- What does the plan pay: a percentage of its allowed amount, or something else?
- Does the plan require approval before visits?
- Is there a visit limit or a telehealth rule?
Record the representative, date and reference number. When the explanation of benefits (EOB) arrives, compare it with what you were told.
Should a group practice give a superbill or submit the claim?
Either route can work, but they split the work differently. With a Superbill, the client sends an itemized statement to the plan and waits for reimbursement. With direct submission, the practice sends the claim to the plan and tracks it. MCM South bills out-of-network claims for clients, so we work on the direct-submission side. Pick one policy for the group and apply it to every clinician. Out-of-network billing for group practices works best with one written rule.
| Question | Superbill | Direct claim |
|---|---|---|
| Who sends it to the plan? | The client | The practice or its billing service |
| Who tracks the claim? | The client | The practice or its billing service |
| Who fixes errors? | The client, with your help | The practice |
| Best fit | Clients who prefer to handle reimbursement | Groups that want claim follow-up handled for them |
Our post on superbill versus billing service goes deeper. Groups may also like our tips on billing for a small group therapy practice. Psychiatrists should read the code basics in our psychiatry billing guide, since E/M and add-on codes follow different documentation rules than psychotherapy.
Private plans, Medicare and state law: keep the rules separate
Do not blend these three. A rule that is true for one is often false for another.
Private insurance
Private plans decide out-of-network coverage by contract and plan design. Benefits, allowed amounts and approval rules differ from plan to plan, so verify each client. Your daily work here is benefits, claims and appeals. See our service page on denied and rejected claim follow-up for the appeal side.
Medicare
Original Medicare does not use networks the way private plans do. Instead, Medicare describes provider types by assignment (checked 10/23/26). A provider who accepts assignment takes the Medicare-approved amount as full payment. A non-participating provider may charge up to a limit above that amount, which Medicare’s page puts at 15%. An opt-out provider generally is not paid by Medicare and uses a private contract. Do not treat these as private-plan out-of-network rules.
State law
State laws on out-of-network care, balance billing and claim payment vary, and a neighbor state’s rule may not apply to you. Find your state’s insurance department through the NAIC state insurance department directory (checked 10/23/26) and ask a healthcare attorney about real exposure.
No Surprises Act and Good Faith Estimates
The No Surprises Act is federal. CMS says providers must give a Good Faith Estimate (GFE) to uninsured or self-pay clients (CMS provider requirements, checked 10/23/26). CMS’s consumer page adds that this includes people who have insurance but do not use it for the care, and that the estimate is due when care is scheduled at least three business days ahead or when the client asks. The CMS pages checked do not describe estimate rules for insured clients whose claims go to the plan, and CMS lists no final rule on advanced explanation of benefits. Rules change, so reconfirm with CMS and your counsel.
When a single case agreement makes sense
A Single Case Agreement (SCA) is a one-time arrangement between a plan and an out-of-network clinician for one member’s care at a negotiated rate. Ask for one when a client needs a clinician the plan’s network cannot supply. The plan decides, and terms differ. Get the rate, visit count, codes and dates in writing before you treat.
How MCM South helps
MCM South Medical Billing Service, LLC works only with mental and behavioral health practices, including groups of psychotherapists and psychiatrists, in ten currently served states. We bill out-of-network claims for clients, check benefits and follow up on denials.
Out-of-network billing for group practices: the short version
Out-of-network billing for group practices works when one written policy covers benefit checks, claims and appeals. Review your out-of-network billing for group practices policy each year, and update it when a payer changes its rules. Share the out-of-network billing for group practices policy with every new clinician.
Frequently asked questions
Is out-of-network billing different for a group than for a solo therapist?
The steps are the same, but a group has more moving parts. Each clinician can have a different network status with each plan, so the group needs one written policy for benefit checks and claim handling.
Can a group practice use superbills for some clients and direct claims for others?
Yes, but a mixed approach can create confusion. Choose a default policy and note any exceptions in the client’s record.
Do Good Faith Estimates apply to out-of-network clients with insurance?
CMS says estimates are required for uninsured or self-pay clients, including people who do not use their insurance for the care. The CMS pages we checked do not describe rules for insured clients whose claim goes to the plan, so reconfirm with CMS.
When should we ask for a single case agreement?
Ask when a client needs a clinician the plan’s network cannot supply. Get the rate, visit count and dates in writing before treatment starts.
Where MCM South works
MCM South works only in mental and behavioral health. We serve psychotherapists and psychiatrists in solo and medium-size practices across ten currently served states: Georgia, Massachusetts, Connecticut, Texas, Florida, New York, Colorado, Tennessee, North Carolina and Illinois. Need a payer contact? Use our insurance companies contact directory.
