Out of Network Billing by Kym Tolson, LCSW, CSAC, Traveling Therapist, Boss Biller
Are you intimidated by out-of-network billing? Is being uncertain of what to do interfering with your income or worse, keeping you from accepting clients who would benefit from your expertise?
It’s important to remember that your client may be confused too. Take control of the situation by making clients aware that they may qualify for out-of-network benefits as early in your interaction as possible. Simply addressing payment options during the initial phone screen will give you an opportunity to address potential benefits they hadn’t considered.
The point is that you and your clients don’t have to fret over the phrase “out-of-network” anymore. Not being contracted with certain providers is not an automatic anxiety-inducing problem. With a bit of knowledge, your confidence will be boosted and your reimbursement secure. All you need is some key terminology defined and a clear path to navigate. Below, you can find both. In addition, you’ll feel supported and less afraid to make a costly mistake.
So let’s get familiar with the basics: generally, there are two ways to bill out-of-network clients:
Generally, that CMS-1500 form centers on the client’s providers who are in-network on insurance panels. Superbills are typically used when you are not contracted with your client’s insurance plan. Your client can simply pay their therapy costs out-of-pocket upfront as noted on the superbill and follow their payment with a submitted request for reimbursement to their insurance company. This affords them proof of their session with you and the specifics regarding your treatment.
Typically, you will generate a superbill that looks like an itemized invoice. A superbill form is easily generated through most EHR platforms. On it, the following information is clearly outlined for your client and their insurance company:
Simply put, the client will receive this bill from you, pay your full rate, and submit the superbill to the insurance company for their own reimbursement according to their benefits.
***Please note: If you do offer a superbill you will be at risk of an audit and potential clawbacks from the insurance company. Many clinicians do not understand if you are dealing with the insurance company, you are eligible to be subjected to audits and the repercussions of those audits.
It’s really up to you. Many therapists provide superbills at the end of every month. Some therapists provide a superbill every session. Still, others generate a yearly bill.
Essentially, the beauty of the superbill is that once you provide it to your client and receive payment, your part is complete. The client assumes responsibility for coordinating and negotiating benefits with their insurance company. Also, once you’re comfortable, you’ll likely find the method is worth your time and consideration as you can quickly and easily provide more comprehensive care options and still obtain your full fee.
Not interested in superbilling?
This billing option meshes direct billing methods and the superbill process. Basically, your out-of-network client still pays your full fee upfront, but you will assume responsibility for submitting the reimbursement forms for them. In this case, your client isn’t burdened with the required paperwork or coordination of funds. When the bill is processed, your client receives the determined reimbursement funds from their insurance company.
Also, when submitting a courtesy bill, do note that there is a difference in how benefits are assigned that you should pay special attention to.
The term “assignment of benefits” refers to a legally binding agreement between the client and their insurance company. When you submit the form for them, it is vital that you are clear about what selecting or not selecting ” Accept Assignment” on the insurance claim means.
Selecting “no” on the form where it asks whether you accept assignment of benefits means that the insurance company understands you do not want anything from them. Thus, your money is still paid upfront. All insurance funds go to the client.
Selecting “yes” on the form means you will not receive upfront pay and must wait for and accept the determined insurance reimbursement. Obviously, not the right option in helping you accomplish your goal for prompt and efficient billing.
I walk you through Out Of Network Billing in Simple Practice Here (https://youtu.be/FpNL1YIlvD0)
Finally, you have the information and a way forward. Do you still need a bit of support? You aren’t alone. I’m here to help. Please reach out now. Moreover, get started, get the guidance, and get your full fee by billing Out Of Network.