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out of network billing tips

 

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).

 

oon billing options

Insurance and Expanding into a Group Practice

First of all—congratulations!

If you are reading this post, that means you are at least thinking about expanding your practice and forming a group, which hopefully means you have a successful group practice or maybe just big dreams!

For the sake of this blog post, I am going to assume that you are in a solo practice with a sole proprietor EIN and have individual contracts with insurance companies.

Here are the steps you should take when expanding from a solo practice to a group practice:

1. Prep work

  • Decide what type of business entity you want to form
    • LLC/PLLC, S-Corp etc.
    • This might include speaking with a lawyer or accountant on which business structure works best for you
  • Obtain an NPI 2
    • Can get one here (the same as your NPI 1).
    • This will be the NPI for your group/organization and is needed for billing.
  • Get a new business bank account for your new group practice/entity
  • Add your new group practice as a new practice location on CAQH and re-attest

2. Contact insurance companies:

  • This will most likely be your network representative or provider relations
  • Express that you are expanding to a group practice and would like a group contract.
    • Give them your sole prop EIN
  • Some insurance companies do not allow for group contracts unless you have a certain number of clinicians. In that case, you will just be changing your tax ID to your new LLC/S-Corp

Insurance and Expanding into a Group Practice

 

3. You will get sent group contracts and most likely group rosters.

  • List yourself as a clinician on the group rosters
  • Use your organizational NPI and your new group EIN
  • If you already have clinicians you are ready to credential, you would also add them to your roster.

4. While waiting for your new group contracts to be executed, you can still bill under your sole prop EIN as usual.

5. Once the contracts are executed, be mindful of the effective date.

  • Any date of service, on the effective date or after can be submitted under the new group EIN.

6. Sign up for electronic funds deposit/EFT using your new group practice bank account.

7. Billing as a group practice:

  • Essentially the same, except in Box 32a and 33a you are putting your NPI 2
  • In Box 33 you are checking ‘organization’ putting your group practice information.
  • You are also using your NEW group practice EIN in box 25

Employee’s NPI 1 in Box 24J

 

Type 2 NPI in Box 32a and 33a and Group Billing/EIN. Group name/billing address in box 33 and check Organization.

If the insurance company does not allow group contracts, you may have to continue to bill under your NPI 1 but with your group practice EIN.

 

Stay tuned for my next blog post about adding clinicians to your group practice contracts. 

In Episode 19, Katia and Danielle interview Dr. Jeremy Sharp, licensed psychologist and Clinical Director at the Colorado Center for Assessment & Counseling, a private practice that he founded in 2009. Jeremy specializes in psychological and neuropsychological evaluation with kids and adolescents. He is also the host of the Testing Psychologist Podcast, providing private practice consulting for psychologists and other mental health professionals who want to start or grow testing services in their practices. Jeremy shares his insight with us into how to manage a practice that is testing based. You can check out more about Jeremy by following links on our page!

Visit our Facebook Page for the show note & more information on this episode.

In Episode 19, Katia and Danielle interview Dr. Jeremy Sharp, a licensed psychologist and Clinical Director at the Colorado Center for Assessment & Counseling, a private practice that he founded in 2009. Jeremy specializes in psychological and neuropsychological evaluation/testing with kids and adolescents. He is also the host of the Testing Psychologist Podcast, providing private practice consulting for psychologists and other mental health professionals who want to start or grow testing services in their practices. Jeremy shares his insight with us into how to manage a practice that is testing based. You can check out more about Jeremy by following links on our FB page!  Read more

In Episode 18, Katia interviews Danielle all about tips and tricks of updating information for a seamless transition when moving offices. While this might seem like a simple one, when it comes to insurance updating your address is essential. Visit the IAP Facebook Page for show notes and resources for this episode.

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In Episode 17, Danielle asks Katia about what she does to prepare for the new year insurance-wise and practice-wise. Topics include: what to ask clients in the new year regarding insurance, how to explain to clients about their deductibles resetting and options to provide them, and general best practices for your practice such as resigning ROIs and gathering your expenses from the last year.

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In this episode, Katia asks Danielle about the process of switching your group practice credentialing over to a solo practice. Danielle answers questions about what you need before switching over your credentialing, how to update the insurance companies with your new practice information, and some pro-tips on how to streamline the process.

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I wrote a blog post for Simple Practice’s Blog on out of network billing options.

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In this episode, Katia and Danielle interview Frances Harvey, CPC the owner of My Solutions Services, an online business management service for clinicians. Topics covered include how an online business management service is different from a virtual assistant, how hiring an online business manager can help you with insurance administrative tasks such as verifying benefits and following-up on unpaid claims as well as give you tips on how to streamline your business. Check out our Facebook Page for the show notes for this episode.

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