Out-of-Network Billing for Therapy Practices: A Simple Guide to Getting Paid

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If you run a small therapy practice, you’ve probably said (or heard): “We’re out of network, but we can give you a superbill and you can submit it to your insurance.”

What that usually means in real life is: nobody really knows what will happen next, the patient is confused, and you’re crossing your fingers it somehow works out.

What “Out-of-Network” Really Means

When you’re in network, you’ve signed a contract with the insurance company. They tell you exactly:

• What they’ll pay you per code

• What rules you have to follow

• Roughly how claims will process

When you’re out of network, there’s no contract. That means:

• You set your own fees

• The plan may reimburse a portion of that to the patient or to you

• Deductibles and coinsurance are usually higher

• There’s a lot more variation from plan to plan

Out-of-network can make sense when:

• In-network rates in your area are too low to be sustainable

• Panels are closed or painfully slow to credential

• You want more control over scheduling, visit length, and mixed services (e.g., PT + wellness, therapy + groups)

But for OON to work as a strategy instead of “vibes and guesswork,” you need three things in place:

1. A consistent benefits verification process

2. Clean claims and tracking

3. Clear patient communication about money and expectations

Step 1: Stop “Winging It” and Standardize Your OON Benefits Check

Most practices “sort of” check benefits and do it differently every single time. That’s how things get missed and money goes sideways.

For every out-of-network patient, you (or your admin) should be able to answer and write down:

• Is this provider type even covered out of network? (LCSW, PsyD, PT, OT, SLP, chiropractor, acupuncturist, etc.)

• Does this plan cover out-of-network office visits at all? Some plans simply don’t. No amount of superbills will fix that.

• What’s the out-of-network deductible?– Total OON deductible– How much has already been met– When the plan year resets

• What’s the coinsurance after the deductible?(e.g., plan pays 60% of the allowed amount, patient pays 40%)

• Any pre-auth or visit limits for this kind of service?

• Who gets paid? Do they send checks/EFT to you (assignment of benefits) or only to the member?

You don’t need fancy software for this. A simple, shared template (Google Sheet, intake form, or spreadsheet) with these fields is enough.

Step 2: Decide How You’re Handling Money On Purpose

Once you know the benefits, you need a clear, default way you handle out-of-network payments. If everyone on your team is improvising, you’re going to have drama.

Most small practices end up in one of these models:

Model A: Full fee up front, insurance reimburses the patient

• You charge your full session rate at time of service.

• You submit the out-of-network claim for the patient.

• The plan reimburses the patient directly.

Pros:

• Clean for your cash flow.

• You’re not waiting on the payer to get paid.

Cons:

• Some patients can’t float the full amount while they wait on reimbursement.

• You have to explain the process clearly so it doesn’t feel like a bait-and-switch.

  
  

Model B: Estimate patient responsibility, reconcile when the EOB comes in

• You collect an estimated patient portion up front (based on benefits).

• After the claim processes, you bill or credit the difference.

Pros:

• Feels “softer” to patients than Model A.

• You’re sharing the risk a bit.

Cons:

• Requires tight tracking and follow-up.

• If your estimates are sloppy, either you lose money or the patient gets a surprise bill.

Model C: Superbill-only (you don’t touch the claims)

• You collect your fee.

• You hand the patient a superbill.

• They’re responsible for submitting and chasing reimbursement.

Pros:

• Lowest admin lift for your team.

Cons:

• Hardest on patients.

• Reimbursement is hit-or-miss.

• The overall experience reflects on you even if you’re “out of it.”

  
  

There isn’t one “right” choice for every practice, but there is a wrong one:

“We’ll just see what happens and figure it out later.”

Whatever you pick, it needs to be:

• Written into your financial policy

• Explained in plain language on your website

• Backed by a simple phone script so patients hear the same thing no matter who they talk to

Step 3: Make Your Out-of-Network Claims Boringly Consistent

Out-of-network claims don’t get a special pass just because you’re not contracted. They still have to be clean claims or they’ll get denied just as fast as anything in-network.

First, make sure your EMR/practice system (Jane, SimplePractice, Prompt, etc.) is actually set up correctly:

• Correct NPI(s), TIN, practice address, and taxonomy

• Correct payer IDs for each plan you’re billing

• Right place of service codes (office, telehealth, home, etc.)

• Standard CPT codes and modifiers locked in (especially for PT/OT and telehealth)

Then, give yourself a boring, repeatable rhythm. For example: Every Tuesday after lunch.

You don’t need a heroic spreadsheet, just something functional with columns like:

• Patient name

• Date of service

• Payer

• Billed amount

• Paid amount and to whom (practice vs member)

• Patient responsibility

• Status: pending / paid / denied / appealed

• Notes (e.g., “need notes,” “recoupment,” “pricing error”)

If you can’t answer “What’s currently outstanding in OON claims and how much is at stake?” in under a minute, your tracking is too loose.

Step 4: Explain Out-of-Network Like a Human

Patients don’t need an insurance lecture. They just need to know what to expect.

You (or your admin) can say something like:

“We’re out of network with your plan, but you do have out-of-network benefits. Your out-of-network deductible is $____ and you’ve met $____ so far. After that, your plan reimburses about ___% of the allowed amount. In our practice, we handle that by [briefly explain your policy: full fee up front / estimated portion / superbill].”

To save everyone time, create:

• A short “How out-of-network works” page on your site

• A simple one-page handout or PDF you can email new OON patients

Same message, every time. Less confusion for them, less re-explaining for you.

Bringing It All Together

Out-of-network billing doesn’t have to be a black box. With:

• A standard benefits check,

• Clear money policies,

• Boringly consistent claims and tracking, and

• Simple, honest patient communication,

you can make OON a real part of your strategy instead of a constant source of stress.

Want Help With Your OON Setup?

If you’re reading this and thinking, “I get it, but I do not have the bandwidth to build all of this myself,” that’s exactly the kind of work I do.

I support:

• PT / OT / SLP and rehab practices

• Mental health practices and groups

• Chiropractic, acupuncture, and massage therapy clinics

with billing, revenue, and operations so you can stop guessing and start using real systems.

You’ve got an easy next step:

• Book an exploratory chat If you know you need deeper, 1:1 help with billing and operations, you can grab a time here:👉 https://calendly.com/daniellewagar/exploratory-chat