In-Network vs Out-of-Network: How Therapy Practices Should Decide

Deciding whether to go in-network or out-of-network is one of the biggest financial decisions a therapy practice makes, and most owners make it by default rather than by design. They sign whatever contracts are offered, or they avoid insurance entirely because someone in a Facebook group told them the rates are terrible. Both paths can work. Both can also quietly cost you tens of thousands of dollars a year if they don't match your market, your capacity, and your goals.

This post is for practice owners, not patients. If you run a PT, OT, or SLP practice, a mental health practice or group, or a chiropractic, acupuncture, or massage therapy clinic, this is the framework I walk clients through when they're trying to make a real decision instead of defaulting to what everyone else does.

The choice affects your rates, how full your schedule is, how much billing and admin work you're signing up for, and how fast money actually shows up in your account. So let's treat it like the business decision it is.

Quick Definitions

In-network means you have a contract with the payer. You agree to their allowed amounts (the fee schedule), follow their rules, and in exchange you typically get more patient volume because you appear in their provider directory and cost patients less out of pocket.

Out-of-network (OON) means no contract. You set your own rates, and the patient's plan may reimburse them based on their OON benefits, usually with higher deductibles and coinsurance.

Neither option is inherently good or bad. What matters is your local market, your caseload goals, your administrative capacity, and your financial reality.

The Three Levers to Think About

Instead of treating this as a binary, think in terms of three levers:

1. Rate per session

2. Volume (how many patients you need to stay full)

3. Admin and billing complexity

In-network gives you a lower rate per session, higher potential volume, and more payer rules to manage. Out-of-network gives you a higher rate per session, lower and more variable volume, and more front-end communication work with patients about benefits and money.

Your job is to decide which combination you can actually sustain, not which one sounds better in theory.

When In-Network Makes Sense

For a lot of new or growing practices, joining a few key plans in-network is a smart move. It tends to be the right fit if:

• Most patients in your market expect in-network care and search that way

• You want fuller schedules quickly, especially across multiple providers

• You're okay trading some structure and rules for predictable volume

• You have (or will build) solid billing systems to handle higher claim volume

The upside: patients understand their benefits, lower out-of-pocket costs mean less friction in saying yes to care, payer directories send you organic referrals, and revenue becomes more predictable once you know the fee schedule.

The downside: lower reimbursement per session, prior auth and visit limits and medical necessity standards, credentialing that can be slow and frustrating, and the reality that some plans are simply not worth joining. Rates can also change under you: if you saw what happened with Aetna's rate cuts for Alma therapists, you know that in-network economics are not set-and-forget.

For most small practices, the real question isn't "all in-network or all OON?" It's: which 2 to 4 plans actually make sense for us to join?

When Out-of-Network Makes Sense

OON can be a strategic choice, not just "the panel was closed so we gave up." It tends to fit when:

• Local in-network rates are too low to sustain your model

• You offer longer sessions or specialized services that aren't viable at contract rates

• Your niche attracts motivated patients with more financial flexibility

• You have the capacity to build clear OON systems: benefits checks, claims support, and money conversations

The upside: you control your rates, schedule, and clinical model, and you can see fewer patients at a higher per-session rate.

The downside: more front-end work explaining benefits, some plans don't cover OON at all, patients need financial flexibility or HSA/FSA funds, and your OON verification and claims workflows have to be solid. OON works when it's intentional and supported by real systems, not "we'll hand them a superbill and hope it's fine."

The Math, Side by Side

Say you're a solo therapist. Your in-network rate is $90 per session and your OON collected rate is $150. These are examples, not gospel, but they're realistic in many markets.

Model	Sessions/week	Rate	Weekly revenue
Mostly in-network	25	$90	$2,250
Mostly OON	12	$150	$1,800
Hybrid: 15 IN + 6 OON	21	$90 / $150	$2,250

On paper, the in-network scenario wins on revenue. But look closer: the OON schedule is 12 sessions instead of 25, which leaves room for documentation, groups, another revenue stream, or a life. And the hybrid model matches the in-network revenue with four fewer sessions per week.

The point isn't to idolize these numbers. It's that in-network buys volume and predictability, OON buys flexibility and margin per hour, and a hybrid lets you combine both.

The Hybrid Strategy (Where Most Mature Practices Land)

Once practices have some data, most of them end up here:

In-network with the big local plans most of their patients carry, plus a few plans that actually pay decently.

Out-of-network with deeply underpaying plans, plans that are a credentialing nightmare, and plans that don't align with their model.

In practice, hybrid often looks like in-network for bread-and-butter services, OON or cash for extended sessions, evaluations, or non-covered services, and just enough in-network volume to keep the pipeline healthy.

The key is that this is a deliberate mix, not an accident. If you're not sure whether your current mix is deliberate or accidental, these 5 signs your payer mix is costing you money are a good gut check.

Five Questions to Decide for Your Practice

1. What does the payer mix look like in my ideal patient base? If 80% of them carry two local plans, there's your starting point.

2. What do the fee schedules actually look like? Not what you hope. What you've seen on EOBs or actual fee schedules.

3. How many clinical hours do I realistically want to work? Could you handle the volume needed at typical in-network rates, or would a hybrid protect your time?

4. What is my admin and billing capacity right now? OON without systems is rough. High-volume in-network without structure is also rough.

5. What do I want my practice to look like in 1 to 3 years? A high-volume, multi-provider in-network group? A smaller, higher-fee, selective practice? Something in between?

Your answers matter more than whatever the loudest person in a Facebook group says.

FAQ

Is it better for a therapy practice to be in-network or out-of-network? Neither is universally better. In-network trades lower rates for higher volume and directory referrals. Out-of-network trades volume for higher per-session rates and more control. The right answer depends on your local market, your capacity, and your financial goals, and many practices run a hybrid of both.

Can a practice be in-network with some payers and out-of-network with others? Yes, and most established practices do exactly this. A common approach is joining the 2 to 4 plans that dominate your local market and pay sustainably, while staying out-of-network with plans that underpay or create excessive administrative burden.

How do I find out what a payer's fee schedule looks like before joining? Request the fee schedule during contracting, before you sign. You can also benchmark against Medicare rates for your codes and region, and compare notes from EOBs if you've billed the payer out-of-network. Never sign a contract without seeing the actual allowed amounts for your most common codes.

If I leave a platform like Headway or Alma, do I keep my in-network status? Usually not automatically. Your participation typically runs through the platform's group contract, so leaving means credentialing under your own contract. If that's your situation, start with how to leave Headway, Alma, or Grow Therapy and start your own practice.

What to Do Next

Deciding between in-network, out-of-network, or a hybrid isn't about vibes. It's math, systems, and your actual life. If every option feels like it has a downside, that's normal. It doesn't mean your practice is broken.

Download our free In vs OON Decision Worksheet to think it through!

in-network-vs-oon-decision-worksheet.pdf

Download PDF • 68KB

If you want a second set of eyes on your specific situation: we can look at your payer mix, your systems, and your goals together and see if working together makes sense.

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You don't have to choose between "sign every contract offered" and "never touch insurance." You're allowed to build a model that supports your patients and your practice.