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

---

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 are in network, you have signed a contract with the insurance company. They tell you exactly what they will pay you per code, what rules you have to follow, and roughly how claims will process. When you are out of network, there is no contract. 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, and there is 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, when panels are closed or painfully slow to credential, or when you want more control over scheduling, visit length, and mixed services like PT plus wellness or therapy plus groups. If you have not settled on a practice model yet, Your Guide to Choosing the Right Private Practice Model walks through that decision in more depth, and if you are weighing OON as part of leaving a platform like Headway, Alma, or Grow Therapy, that transition guide covers how the OON decision fits into a full exit plan. But for OON to work as a strategy instead of vibes and guesswork, you need three things in place: a consistent benefits verification process, clean claims and tracking, and clear patient communication about money, expectations, and your Good Faith Estimate obligations under the No Surprises Act.

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 is 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 whether this provider type is even covered out of network, whether the plan covers out-of-network office visits at all (some plans simply do not, and no amount of superbills will fix that), what the out-of-network deductible is and how much has already been met, what the coinsurance looks like after the deductible, whether there are pre-authorization requirements or visit limits for this kind of service, and who actually gets paid. Some plans send checks or EFT directly to you under an assignment of benefits, while others will only pay the member. If terms like allowed amount and coinsurance still feel fuzzy to your team, What "Allowed Amount" Really Means breaks down exactly how payers land on those numbers.

ou do not need fancy software for this. A simple, shared template in a Google Sheet or intake form with these fields is enough to keep your team consistent. If you want a more structured walkthrough of exactly how to verify and interpret OON benefits before you ever see the patient, the Out-of-Network Benefits Guide covers this step in detail.

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 are going to have drama.

Most small practices end up in one of three models. In Model A, you charge your full session rate at time of service and submit the claim for the patient, who is reimbursed directly by the plan.

This is clean for your cash flow and you are not waiting on the payer to get paid, but some patients cannot float the full amount while they wait on reimbursement, and you have to explain the process clearly so it does not feel like a bait and switch.

In Model B, you collect an estimated patient portion up front based on benefits, then bill or credit the difference once the claim processes and the EOB comes in. This feels softer to patients than Model A and shares the risk a bit, but it requires tight tracking and follow-up, and sloppy estimates mean either you lose money or the patient gets a surprise bill.

In Model C, you collect your fee, hand the patient a superbill, and they are responsible for submitting and chasing reimbursement themselves. This is the lowest admin lift for your team, but it is hardest on patients, reimbursement is hit or miss, and the overall experience still reflects on you even though you are out of the claims process.

There is not one right choice for every practice, but there is a wrong one: deciding to just see what happens and figure it out later. Whatever you pick needs to be written into your financial policy, explained in plain language on your website, and backed by a simple phone script so patients hear the same thing no matter who they talk to.

Step 3: Do Not Skip the Good Faith Estimate

Here is the piece that gets missed more than any other, and it is federal law, not a nice-to-know.

Under the No Surprises Act, if a patient is paying you directly rather than having a claim submitted on their behalf, you almost certainly owe them a Good Faith Estimate, or GFE. This applies to mental health and rehab providers just as much as it applies to hospitals and surgeons. No specialty is exempt.

The obligation shows up most often in Model C, where the patient is self-pay by definition, and it can show up in Model A as well depending on how your intake is structured. The general rule is that a patient counts as self-pay for GFE purposes if they are uninsured, or if they are insured but choose not to have a claim submitted to their plan for that service. If your practice is the one submitting the claim on the patient's behalf, as in true OON billing under Model A or B, the GFE requirement generally does not apply in the same way, since the patient is not self-pay in that scenario. The distinction matters, so when in doubt about which of your patients fall into which bucket, treat it as a compliance question worth getting right rather than guessing.

When a GFE is owed, you need to provide it before the first session, and again any time the expected course of treatment changes significantly, such as a jump from weekly to twice weekly sessions or the addition of a new service like psychological testing. If a patient simply asks what something will cost, that request alone triggers the obligation, even if nothing is scheduled yet.

The estimate itself needs to include your name, NPI, and tax identification number, the expected services and codes, a reasonable estimate of cost over the expected treatment period, and the required disclaimer language about the patient's right to dispute a bill that ends up four hundred dollars or more above the estimate. If the service is scheduled at least three business days out, the GFE is due no later than one business day after scheduling. Cutting it close on timing is one of the most common compliance gaps we see.

Build the GFE into the same intake workflow where you are already collecting OON benefit information. If a patient is self-pay or out-of-network without claims submission, the GFE conversation should happen at the same time you are explaining your financial policy, not as an afterthought tacked on at the end of the first session.

Step 4: Make Your Out-of-Network Claims Boringly Consistent

Out-of-network claims do not get a special pass just because you are not contracted. They still have to be clean claims or they will get denied just as fast as anything in network.

Start by making sure your EMR or practice system, whether that is Jane, SimplePractice, Prompt, or something else, is actually set up correctly. That means correct NPI, TIN, practice address, and taxonomy, correct payer IDs for each plan you are billing, the right place of service codes for office, telehealth, or home visits, and standard CPT codes and modifiers locked in, especially for PT, OT, and telehealth.

Then give yourself a boring, repeatable rhythm. Every Tuesday after lunch is a perfectly reasonable cadence. You do not need a heroic spreadsheet, just something functional that tracks patient name, date of service, payer, billed amount, paid amount and to whom, patient responsibility, status, and notes on anything unusual like a recoupment or a pricing error. If you cannot answer what is currently outstanding in OON claims and how much is at stake in under a minute, your tracking is too loose. For a complete repeatable system covering this from intake through payment, Intake to Income: The Complete Billing Workflow walks through the full process step by step.

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, put together a short how-out-of-network-works page on your site and a simple one page handout or PDF you can email new OON patients, along with their GFE where applicable. Same message, every time. Less confusion for them, less re-explaining for you.

Bringing It All Together

Out-of-network billing does not have to be a black box. With a standard benefits check, clear money policies, a reliable Good Faith Estimate process, 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 are reading this and thinking that you get it but do not have the bandwidth to build all of this yourself, that is exactly the kind of work I do. I support PT, OT, SLP, and rehab practices, mental health practices and groups, and 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 a session - If you know you need deeper, 1:1 help with billing and operations, you can grab a time here:👉 https://calendly.com/daniellewagar/strategy-session-intensive-60-minutes