Out-of-Network Billing for Therapists: What to Ask a Billing Service
Out-of-network billing for therapists means you are not in a payer’s contracted network, yet your clients may still have out-of-network benefits. You can bill the plan on the client’s behalf, or give the client a superbill to file. Either way, the details matter. This guide covers the steps and the questions to ask any billing service. MCM South bills out-of-network claims for clients.
What is out-of-network billing for therapists?
When you are in network, you accept the payer’s contracted rate. Out of network, you set your own fee, and the plan pays based on the client’s out-of-network benefits and its own allowed amount. Read our guide to in-network vs out-of-network for the full comparison, and the credentialing side of the choice.
7 steps to bill out of network
- Verify out-of-network benefits. Ask about the deductible, coinsurance and any visit limits. See insurance verification and eligibility checks.
- Set your fee and policy. Put it in writing in your informed consent paperwork.
- Give a Good Faith Estimate when required. See the note below.
- Document every session. Notes must support the code you bill.
- Choose how to bill. Submit the claim yourself or through a service, or give a superbill to the client.
- Track timely filing. Out-of-network plans still set deadlines. See timely filing.
- Follow up. Check payment, correct errors and appeal denials.
Good Faith Estimates and the No Surprises Act
The CMS Good Faith Estimate FAQ says the requirement covers uninsured and self-pay individuals. For insured clients who want a claim submitted to their plan, the FAQ says enforcement was deferred pending rulemaking. This status can change, so confirm it with CMS and your counsel before you rely on it. Our No Surprises Act glossary entry gives the background.
Private payers vs Medicare vs Medicaid
Private payers. Out-of-network benefits depend on the plan. Some plans have none, such as certain HMO and EPO products, so verify before the first visit.
Medicare. Medicare has its own enrollment and participation rules, so the private out-of-network model does not map over directly. See our Medicare behavioral health billing guide.
Medicaid. Medicaid generally pays only enrolled providers, and rules vary by state. Check your state Medicaid agency.
What to ask an out-of-network billing service
- Do you submit claims directly, or only prepare superbills?
- Who checks benefits and how do you share the results with me?
- How do you track timely filing and denials?
- What do I see in reports?
- Will you sign a business associate agreement? See HIPAA for billing.
Learn more about electronic claims submission, denial follow-up and appeals, what a billing service for therapists includes, outsourcing therapy billing and how therapists pay a billing service. See who we serve.
Frequently asked questions
Can I bill insurance if I am out of network?
Often yes, on the client’s behalf, if the client’s plan has out-of-network benefits. Verify the benefits first.
What is a superbill?
A superbill is an itemized receipt with the codes, diagnosis and fees that a client can submit to their plan for reimbursement.
Do I need a Good Faith Estimate for every client?
It depends on whether the client is uninsured or self-pay and on current federal guidance. Confirm with CMS and counsel.
Is billing a client directly the same as being out of network?
Not exactly. Out of network describes your status with the payer. How you collect payment is a separate choice.
Put your policies in writing. Out-of-network billing for therapists runs smoothly when the client understands the process, so explain your approach to out-of-network billing for therapists in your consent paperwork.
Many practices start with a few clients and grow. Out-of-network billing for therapists scales well when the process is repeatable, and a repeatable process for out-of-network billing for therapists is what a good billing service gives you.
Where MCM South Medical Billing Service Works
MCM South Medical Billing Service, LLC works with psychotherapists and psychiatrists in our ten currently served states: Georgia, Massachusetts, Connecticut, Texas, Florida, New York, Colorado, Tennessee, North Carolina and Illinois.
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