Out‑of‑Network Billing Services – Simplify Superbill Submission & Balance Billing
What is Out‑of‑Network Billing & Why Providers Use it?
Why Providers Require Out-of-network Reimbursement Support?
Healthcare practitioners require services of a trained and professional out-of-network medical billing company to submit claims for offering medical care to patients who are not in their approved health insurance network. Treating such patients without knowing the rules and policies of insurance payers not only puts your practice at financial risk, but also causes shocks to patients, who’ve to pay claims value entirely from their pocket.
Medheave as the #1 trusted platform in the USA helps medical practitioners in superbill generation and claim submission for patient insurance coordination for OON billing and coding. Outsource today and expand the medical care services to patients from approved and out of network programs to collect every penny owed by payers.
Key Differences: In‑Network vs.
Out‑of‑Network Billing
| In-Network Billing | Details |
|---|---|
| Contract W/Payer | Healthcare provider signed contract with insurance company to charge every patient of that specific company at mutually-agreed rates |
| Payment Process | Claims are submitted to payers and typically processed with ease and less likely to be rejected |
| Reimbursement Rates | Typically lower than self-pay or out-of-network, but more consistent and can be adjusted for inflation after a fixed time. |
| Patient Volume | Providers get access to a higher number of patients as everyone prefers approved in-network doctors. |
| Administrative Burden | Lower administrative burden due to familiarity with payer’s system and policies |
| Revenue Cycle | Streamlined, flexible and predictable for maximization of revenue collection |
| Out-of-Network Billing | Details |
|---|---|
| No Contract W/Payer | Providers can charge standard or higher rates depending on nature of medical care |
| Payment Process | Can be 100% self-pay or may have some form of assistance such as specific % that can be charged to the insurance payer. |
| Reimbursement Rates | Higher than in-network but time and policy dependent. More prone to rejection if done by an unskilled billing team. |
| Patient Volume | Lower patient volume due to being expensive and mostly patients are for emergency or urgent care treatments |
| Administrative Burden | Higher administrative burden due to multitude of complexities pertaining to government and commercial payer policies often in conflict with provider’s payment process |
| Revenue Cycle | High volatility due to dependence on patients’ payment capacity and acceptability by insurance payer’s policies |
How Medheave Manages Out‑of‑Network Billing
for Your Practice
Timely Eligibility Checks (insurance verification)
Out-of-network payer reimbursements services of Medheave ensures timely insurance eligibility checks and verifications from payers without any delay for all healthcare facilities including hybrid private practice models.
Professional Superbill Generation in CMS-1500 Format
Our superbill processing service streamlines the out-of-network claim submission by generating error-free superbills for payers and patients for optimized self-pay and OON claims coordination.
Fast Claim Submission to Carriers (including Allied Administrators)
Out of network billing and coding experts of our company offer faster claim submissions and balance billing for therapists to help you get reimbursed within designated timeframe.
Patient Statement Workflows Via Email/mail/text
To help providers in minimizing administrative burden on in-house teams and maintaining balance billing workflow, we expedite the patient statement issuance via email and mail.
Full Denial Tracking & Appeal for OON Rejections
We help healthcare providers with best out-of-network denial management services enabling these practices to have AI-powered high dollar claim follow-up and rapid appeal filing on rejections/denials.
Monthly Reporting Dashboards for Aging AR
OON billing services we offer keep healthcare professionals updated via periodic performance reports on key financial metrics, empowering them to make informed decisions backed by data.
Why Out‑of‑Network Billing is Challenging Without a Partner
- UCR reimbursement complexity
- Superbill formatting errors leading to claim rejection
- Lack of internal staff for patient follow-ups or appeals
- High administrative burden on providers
Case Studies & Performance Metrics
- 95% superbill acceptance rate
- 40% faster payment vs DIY billing
- AR recovery within ≤ 30 days
- US-based certified out-of-network billing specialists
- HIPAA-complaint OON billing solutions
- RCM team knowledgeable in government & commercial payer policies
- Complete AR & denial management services
- Error-free superbill generation and rapid submission
Ready to simplify OON billing and get paid faster? Book a free audit or request a billing demo today
Frequently Asked Questions (FAQs)
What codes should I include on a superbill for OON claims?
Healthcare providers/therapists can add the following codes as per treatment or procedures offered to patients including:
CPT Codes (Current Procedural Terminology)
These codes describe the services or procedures provided.
For example, in therapy:90832 – 30-minute session
90834 – 45-minute session
90837 – 60-minute session
These codes help insurers understand what was done during the visit.1
ICD-10 Codes (International Classification of Diseases)
These codes explain why the service was provided — the diagnosis.For example:
F41.1 – Generalized anxiety disorder
F32.1 – Major depressive disorder, moderate
These codes justify the CPT codes and are crucial for reimbursement
How do you set UCR rates for my clinic?
- Define the Services
- Research Local Market Rates
- Determine Percentile Benchmarks
- Ensure Consistency
- Document and Justify
