Question 1

Does Every Client with Health Insurance Have Some Coverage?

Accepted Answer

Depending on the health insurance plan, some clients will have out-of-network coverage, and some will not. Health maintenance organization (HMO) plans and exclusive provider organization (EPO) plans only cover in-network providers. If you are not an in-network provider with a certain insurance company and a client has an HMO or EPO through that company, they will not have any coverage for your services as an out of network provider.

However, clients with preferred provider organization (PPO) plans or point-of-service (POS) plans receive coverage for both in-network and out of network providers. All this means for a client is that they may pay more when they go out of network, but they will still have some coverage and can receive out of network reimbursement.

Question 2

How Does Out of Network Insurance Billing Work?

Accepted Answer

Ideally, the client will pay an out of network provider in full at the time of the session. However, some out of network providers opt to bill clients periodically, such as at the end of the month. If you are an out of network provider, you can give your client a superbill after receiving full payment. A superbill reflects that the client did pay you for the services. A superbill should include the following information:

Your name
Your contact information
The date of the invoice
The client name
The client's date of birth
The diagnosis codes
The place of service code
The Current Procedural Terminology (CPT) code
The modifier number, if applicable
A description of the service
Your charge for the session
The amount you collected
Your signature
Your license number
Your Employer Identification Number (EIN) or Social Security number
Your NPI

If the client has out-of-network coverage, they can then submit the superbill to their insurance plan and try to get out of network reimbursement. In an ideal scenario, the client's insurance would partially reimburse them. Encourage your clients to submit their superbills as quickly as possible, especially if they are counting on reimbursement or issues arise that need clarification.

Question 3

Can an Out of Network Clinician Bill Insurance Directly and Bill Clients for the Remainder?

Accepted Answer

Yes, you can bill an insurance company directly and then bill your client for the remainder of the cost. Remainder billing means the client does not have to pay in full at the time of the service. For example, if a client has 50% out-of-network coverage, the insurance company will pay you 50%, then you bill the client the remaining 50% of the payment.

This billing method can be risky, however. In some cases, the insurance company may send the payout to your client instead of you, as that is usually the process with out-of-network providers. The client may also fail to pay their part of the bill, which could mean you do not receive full payment for your sessions.

Question 4

What if the Health Plan Reimburses the Clinician Instead of the Client?

Accepted Answer

If you give your client a superbill and they submit the bill to their health plan, the health plan may inadvertently write you a check instead of the client. This could be a tricky situation. Though the simplest option may be to sign the check over to the client, the health plan may realize their mistake and ask you for the money back. If you have already given this money to the client, you could be in a difficult position.

Avoid signing the check over to the client or cashing it. Instead, the best solution is to have your client contact their insurance plan and alert them that they paid the wrong person. The client can then request that the payment stops or ask how to handle this situation.

Question 5

What if a Client Only Wants a Receipt?

Accepted Answer

Sometimes, your client may simply want a receipt, not a superbill to submit to insurance. They may want this receipt for tax purposes, for example. While you can give a client information for their records, there is no need to include diagnosis or CPT codes. Instead, keep it general and create a business receipt showing the client paid for behavioral health services.