Out of Network Billing Tips

billing insurance out of network quick tips super bill Jul 08, 2018

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


  • 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).

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