6 min read

Understanding Out-Of-Network Billing

Out-of-network (OON) billing is a win-win for therapists and your clients, allowing you to keep cash pay therapy accessible for your clients while still charging your full fee.
Written by
Rachel Hodes
Published on
May 26, 2024

Understanding Out-of-Network Billing

Out of network (OON) billing is a win-win for therapists and your clients, allowing you to keep cash pay therapy accessible for your clients while still charging your full fee. Out of network billing allows cash pay clients to get money back on therapy by leveraging their insurance out-of-network benefits.

Instead of having to choose between making a living wage or staying in-network with insurance to keep therapy accessible for clients who need it most, out-of-network billing allows you to reduce the cost of therapy for your clients while still getting your full fee upfront, guilt-free.

How Does Out-of-Network Billing Benefit My Clients?

Many clients mistakenly believe they must choose between seeing a therapist who accepts their insurance or paying $200 for weekly cash pay sessions. They often don't realize that many insurance plans offer out-of-network benefits for therapy, which can reimburse them for a significant portion of their session costs. Depending on their plan, clients could get up to 80% back! Clients who receive reimbursement for their cash pay sessions are more likely to continue therapy for as long as they need.

You can reduce the sticker shock of therapy if your clients know how much they can save on their sessions before they begin working with you. Clients who have the right knowledge at the outset are empowered to work with the therapist they feel the most connected to, over someone who they may feel less comfortable with but is in-network for them.

Key Points for OON Therapists:

Out-of-network billing is ideal for therapists who want more control over their practice structure and fee setting. With out-of-network (OON) billing, you set your own fees and collect them directly from your clients. This gives you the freedom to structure your practice according to your values and expertise.

To initiate the reimbursement process for out-of-network therapy, you can submit claims to your clients’ insurance instantly through Mentaya or provide your clients with a superbill for them to submit on their own. Claims must be submitted both before and after reaching your clients’ deductible to receive reimbursement. If you choose to work with Mentaya, we will handle the reimbursement process from start to finish for you and your clients!

How Does Out-of-Network Billing Differ from Taking Insurance?

If you choose to be in-network with insurance, you agree to provide services at a set fee determined by the insurance company. The insurance company pays you directly, while your clients are typically responsible for a copayment or coinsurance. This arrangement requires you to accept rates that insurance companies deem "acceptable" for therapy costs, which can limit your freedom to set your own fees.

In-network providers have a contractual agreement with insurance companies to offer services at pre-negotiated rates. On the other hand, out-of-network providers do not have such agreements. Clients pay the therapist directly and may seek reimbursement from their insurance company if their plan allows.

Disadvantages of Being In-Network:

  1. Lower Reimbursement Rates: Insurance companies often negotiate lower rates for services, which can significantly reduce the therapist’s income.
  2. Administrative Burden: There is a substantial administrative burden involved, including handling paperwork, claims, and dealing with insurance companies for approvals and reimbursements.
  3. Limited Autonomy: Therapists may have less control over their practice, as they must adhere to the insurance company's policies and guidelines for treatment.
  4. Delayed Payments: Insurance companies often delay or claw back in-network payments, which can create distressing cash flow issues.

The Advantages of Out-of-Network Billing:

  1. Financial Benefits: The ability to set higher rates and avoid low insurance reimbursements can lead to significantly better financial outcomes for therapists.
  2. Clinical Autonomy: Therapists retain full control over their clinical decisions, allowing them to provide the best possible care without constraints from insurance policies.
  3. Reduced Administrative Hassles: By avoiding the complex and time-consuming paperwork associated with insurance claims, therapists can focus more on patient care and less on administrative tasks.
  4. Improved Cash Flow: Upfront payments from clients lead to a more stable and predictable cash flow, reducing the financial stress associated with delayed insurance payments.

Out-of-network billing offers therapists greater financial benefits, autonomy, and reduced administrative burdens. These advantages can lead to a more satisfying and sustainable practice, making out-of-network billing the preferred option for many therapists.

Why Can’t I Just Give My Clients Superbills?

It’s easy to think that providing a bulk superbill every month to your clients is enough to kick off the reimbursement process and keep them coming back to therapy. However, we find that more often than not, superbills end up forgotten in their junk drawer, never making their way to insurance.

Leaving clients to navigate the complex insurance processes on their own can put their reimbursement at risk and contribute to them having to quit therapy before they’re ready.

The Challenges of Superbill Submission

At Mentaya, we believe that your clients shouldn’t have to be insurance experts just to access their benefits! Navigating confusing coverage policies by calling their insurance to verify their out-of-network benefits is often the first step in an unnecessarily complex process. Superbill submission can be overwhelmingly tedious and time-consuming.

Even after your clients brave the complex insurance hoops and spend ages successfully submitting their superbills to insurance, there are many reasons why a superbill could be rejected that clients do not have the ability to resolve on their own. Here are some common issues:

  1. The Superbill has Missing or Incorrect Information:
    • The Problem: The intricacies of coding and billing are specialized areas that can be challenging to navigate, and two codes might not be able to be billed together or applicable for that type of session.
    • How Mentaya Helps: Mentaya’s expert billing team can advise on how different CPT codes interact, and our product has built-in guardrails to ensure that all claims contain the necessary information to minimize denials from insurance.
  1. The Therapist is Not Recognized by the Insurance Company:
    • The Problem: Some insurance companies require therapists to be explicitly listed as out-of-network providers.
    • How Mentaya Helps: Mentaya offers complimentary out-of-network registration services with insurance so the claims are not denied.
  1. Reimbursement Gets Sent to You (the Therapist), Not your Client:
    • The Problem: For some insurance plans, it is their policy to send reimbursement to the therapist, not the client. This puts the therapist at risk of clawbacks and reimbursement can be tedious to send to clients.
    • How Mentaya Helps: Mentaya can prevent reimbursement from being sent to you, and we can redirect that reimbursement to your clients and take on the risk of clawback.

If your clients are transitioning to Mentaya but have past superbills, we recommend they bulk upload their past superbills directly to Mentaya. Our team checks that for errors that need to be corrected upfront and handles the follow-up on your clients’ behalf, addressing issues that clients wouldn’t have the power to fix on their own. Mentaya is entirely risk free, which means we guarantee that claims are successfully submitted to insurance or a full refund of our fees!

How do I Know if my Clients are Eligible for Reimbursement Through Mentaya?

To find out if your clients are eligible for reimbursement through Mentaya, you can use our instant benefits checker to determine your clients’ out-of-network benefits in seconds.

Clients with insurance plans that include out-of-network benefits, such as Preferred Provider Organizations (PPOs), Point-of-Service (POS) plans, and High-Deductible Health Plans (HDHPs), are typically eligible for reimbursement.

However, HMOs, Medicaid, and traditional Medicare plans do not have out-of-network benefits and are not eligible for reimbursement through Mentaya. Clients with Tricare often need to get a single case agreement / authorization in order to get reimbursed for out-of-network therapy, but our team has seen great success with reimbursement from Tricare plans.

How Much Can my Clients Save on Therapy? What is Mentaya’s Success Rate?

The specific amount reimbursed depends on your clients’ individual out-of-network coverage. As an example, if your client’s coinsurance is 30%, they can expect to be reimbursed 70% of the allowable amount. The average reimbursement through Mentaya is 62%, and in some cases can be up to 80%.

If a client pays for therapy out-of-pocket, they can potentially get back a significant portion of their expenses through insurance reimbursement by using Mentaya. We fully handle all the insurance paperwork and follow-up, and our services include a guarantee of successful claim submission or a full refund of our processing fees.

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