Not every practice is in network with every plan, and some choose not to be in network at all. Out-of-network billing is how those practices still get paid by insurance, either directly from the plan or through a patient’s reimbursement. It takes different work than in-network billing: there is no contracted rate, benefits vary widely from plan to plan, and payment can go to the patient instead of the practice. Maximum Billing handles out-of-network claims and superbills for therapy, behavioral health, psychiatric, medical, and dental practices in twelve states.
Schedule a consultation or call 800-820-0364.
What Out-of-Network Billing Means
A practice is out of network with a plan when it has no contract with that plan. Without a contract, the plan does not use a negotiated fee schedule. It pays from the patient’s out-of-network benefits, based on its own allowed amount for the service, after the patient’s out-of-network deductible and coinsurance. Whatever the plan does not pay is usually the patient’s responsibility, subject to state and federal rules.
There are two common ways an out-of-network practice gets paid:
- The practice submits the claim. The practice bills the plan as a non-participating provider, and the plan pays the practice or the patient, depending on the plan and the assignment of benefits.
- The patient submits a superbill. The patient pays the practice in full, and the practice gives the patient a superbill to send to their plan for reimbursement.
We handle both. Many practices use a mix: claims for some plans and patients, superbills for others.
What We Handle
- Out-of-network benefit checks before the first visit: whether the plan has out-of-network benefits at all, the out-of-network deductible and how much has been met, coinsurance, and any authorization the plan requires.
- Out-of-network claim submission with the right codes, modifiers, place of service, and provider details, sent as a non-participating provider claim.
- Follow-up on unpaid claims, because out-of-network claims can take longer to process and often need more follow-up.
- Denials and appeals when a plan denies or underpays an out-of-network claim.
- Payment posting, including tracking claims where the plan paid the patient instead of the practice.
- Superbills with everything a plan needs to process a reimbursement request. Our guide to superbills for therapists lists what one should include.
Check Out-of-Network Benefits First
Out-of-network benefits vary more than in-network benefits, and a quick eligibility check that only confirms active coverage misses most of what matters. Before the first visit, it helps to know:
- Whether the plan has out-of-network benefits. HMO and EPO plans often have none. PPO and POS plans usually do.
- The out-of-network deductible. It is usually separate from the in-network deductible, and often higher.
- Coinsurance. The share the plan pays after the deductible.
- How the plan sets its allowed amount. The plan reimburses from its own allowed amount, not from your fee, so the patient’s reimbursement can be well below what they paid.
- Authorization and filing limits. Some plans require authorization for out-of-network services, and every plan has a deadline for submitting claims.
An example: if your fee is $175, the plan allows $120, and the plan pays 70% after the deductible is met, the plan pays $84, not 70% of $175. Telling patients this before the first visit helps prevent out-of-network billing complaints. Our insurance verification services cover in-network and out-of-network checks.
Claims or Superbills: Which Works Better?
Submitting claims for patients is more work for the practice, but it removes a barrier for patients who would otherwise have to file their own reimbursement. Superbills keep your revenue predictable, because the patient pays at the time of service, but some patients never submit them and stop coming when the cost feels too high.
The right mix depends on your patients, your fee, and the plans in your area. We can bill out-of-network claims for the plans where it makes sense and produce superbills for everyone else.
Where Out-of-Network Claims Go Wrong
- The plan pays the patient. Many plans send out-of-network payments to the member. If the practice is not tracking it, the claim looks unpaid and the patient keeps the check.
- The plan has no out-of-network benefits. A claim to an HMO or EPO plan without out-of-network coverage is usually denied in full.
- Missing provider details. Out-of-network claims still need the rendering provider’s NPI, tax ID, license, and credentials, and plans deny claims that leave them out.
- Missed filing deadlines. Out-of-network claims and superbills both have time limits. Superbills held for months can push older visits past the deadline.
- Missing authorization. Plans that require authorization for out-of-network care may deny claims without it.
The Rules That Apply
Federal and state rules affect how out-of-network care is billed. Under the No Surprises Act, since January 1, 2022, providers must give a Good Faith Estimate of expected charges to patients who are uninsured or not using insurance, including patients who pay directly and submit their own superbills. The same law protects patients from surprise balance bills for emergency care and for certain care at in-network facilities.
Some states add their own rules. New Jersey, for example, requires providers to tell patients their network status before scheduling non-emergency services. Our New Jersey medical billing page covers the state’s Out-of-network Consumer Protection, Transparency, Cost Containment and Accountability Act.
Thinking About Going In Network?
Some practices bill out of network while they wait for credentialing to finish, and others decide to join a plan after seeing how many patients use it. If you want to join a plan’s network, our behavioral health credentialing, medical credentialing, and dental credentialing services handle the applications.
Practices We Work With
We bill for therapists and group practices, psychiatrists and psychiatric nurse practitioners, medical practices, and dental practices. See our therapy billing services, psychiatric billing services, dental billing services, and mental and behavioral health billing services.
We work inside the system you already use, including SimplePractice, Sessions Health, TherapyNotes, and InSync for behavioral health practices, and Eaglesoft, Dentrix, Dentrix Ascend, and Open Dental for dental practices. We sign a Business Associate Agreement with every client, and every team member completes HIPAA certification. As of 2026, our clients’ claims reach a 91% clean claim rate, and their accounts receivable average 34 days.
Frequently Asked Questions
Can you bill insurance if we are not in network?
Yes. We submit claims to the plan as a non-participating provider, follow up until they are paid or resolved, and post the payments, including payments the plan sends to the patient.
Do you check out-of-network benefits?
Yes. Before the first visit, we check whether the plan has out-of-network benefits, the deductible and coinsurance, and any authorization requirements.
Can you create superbills for our patients?
Yes. We produce superbills with the codes, provider details, and signature a plan needs to process a reimbursement request.
Do we have to change our software?
No. We work inside the practice management system you already use.
Get Paid for Out-of-Network Care
Tell us which plans your patients use and how you bill them today, and we will review how your out-of-network claims are handled today. Contact us to schedule a consultation, or call 800-820-0364.