2 Options for Out-of-Network Insurance Billing

As a therapist or counselor in private practice, you may find yourself feeling conflicted about whether you want to get credentialed or paneled to work in-network with health insurance companies.

However, in order to serve your clients and help them afford the cost of therapy, it’s essential to understand the basics of in-network and out-of-network insurance billing.

Whether or not you have gotten credentialed or paneled with an insurance provider, you may still choose to see clients who have different health insurance and are out-of-network.

In these cases, you may find yourself asking: “How do I submit an out-of network claim on behalf of a client or patient?” or “What’s a superbill, and how does it work?“

SimplePractice is here to help! Here are two options for billing as an out-of-network provider.

Option 1: Provide the client with a ‘superbill,’ and the client will file the claim to get reimbursed by their insurance company

Superbills are the option that most out-of-network clinicians use. Think of a superbill as a detailed receipt of the client’s session. It is not just a regular invoice or statement, it has very similar information that a claim form would have, except it is more client friendly.

Choosing to use a superbill puts most of the work on the client. (Whether this is the best course of action for your practice is for your decide.)

Information included on a superbill 

• The client’s name, date of birth, address and insurance information (company, ID/Group etc.)
• The clinician’s name, tax ID, NPI, office address
• The dates the session took place (Dates of Service), CPT codes used and the client’s diagnosis
• The amount charged for the session and the amount the client paid
• Who payments should go to (client in this case)

Sounds similar to an actual claim form, right?

How to create a superbill with SimplePractice

The SimplePractice EHR can easily generate superbills for you.

Here’s how.

First, click on the billing tab in the client’s profile. Then, click the “create” button and select “superbill.”

From this screen, you can choose to print, download, or send the superbill to the client by email. If you only want to have specific sessions show up on the superbill, you would select the date range to include only those sessions, and then create the superbill.

 

 

The client would then use the information provided on the superbill to submit the claim to their insurance company in order to get reimbursed for their sessions.

They can usually do this on the insurance company’s member website or portal.

Option 2: Submit an out-of-network claim on the client’s behalf

Submitting out-of-network insurance claims is the option I prefer because I like to offer a complete billing service for my clients regardless of their insurance, and it really does not take me much time at all.

Billing an insurance company as an out-of-network provider is very similar to billing when you are in-network.

However, there are a few differences to note.

How to submit an out-of-network claim

To submit an out-of-network insurance claim using the SimplePractice EHR, you would set up the client’s insurance like you would if you were in-network, but you would select “enable additional fields” link in the client’s billing and insurance tab and select “No” where it says accept assignment.

 

 

This puts a “No” in box 27 on the claim form to indicate that you want the insurance company to reimburse the client and not the clinician. This also unchecks box 13 on the claim form. Think of these boxes as saying: “Should we send the payment to the clinician? Yes or No?”

This is the biggest difference between in-network and out-of-network billing. When you are in-network, Boxes 13 and 27 are always marked “Yes,” because you want the insurance company to send the payment to you, the clinician.

When you are out-of-network you have the option of sending the payment to the clinician or to the client. If the client would pay you your full fee as an out-of-network provider, you would indicate this on your claim form and select “No” in boxes 13 and 27 so that the insurance company reimburses the client.

Another major difference is with government health care plans such as TRICARE and Medicare. TRICARE requires out-of-network providers to apply to be out-of-network providers before being able to bill. Medicare has no out of network benefits and you must be an eligible Medicare provider for claims to get accepted.

Insurance guru pro tip:

Even if you are out-of-network with an insurance company, I would still verify the client’s out-of-network benefits. This way the client knows if they have a deductible to meet (most out of network insurance benefits have higher deductibles) before they will get reimbursed by the insurance company.

How SimplePractice streamlines running your practice

SimplePractice is HIPAA-compliant practice management software with everything you need to run your practice built into the platform—from booking and scheduling to insurance and client billing.

If you’ve been considering switching to an EHR system, SimplePractice empowers you to streamline appointment bookings, reminders, and rescheduling and simplify the billing and coding process—so you get more time for the things that matter most to you.

Try SimplePractice free for 30 days. No credit card required.

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