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).
