How out-of-network billing for therapists works
Out-of-network billing for therapists covers every way a clinician who is not contracted with a client's health plan gets paid, and every way that client can recover part of the cost. The therapist sets their own fee, the client usually pays at the time of service, and the plan may reimburse the client under out-of-network (OON) benefits.
Because there is no contract, the plan has not agreed to your rate and you have not agreed to its rules on fees or balance billing. That freedom comes with work: clients need to understand their benefits, they need correct documentation, and you need to meet federal estimate rules for self-pay clients.
The four common arrangements are superbills, courtesy billing, single-case agreements and pure private pay with no insurance involvement. Many practices use more than one, depending on the client.
Out-of-network benefits: the terms clients need explained
Most confusion in OON billing comes from benefit terms. A two-minute explanation at intake prevents weeks of frustrated emails later.
| Term | What it means for a therapy client |
|---|---|
| OON deductible | A separate amount the client pays before OON reimbursement starts; often higher than the in-network deductible |
| Allowed amount | The plan's own figure for the service, which may be well below your fee |
| Coinsurance | The share of the allowed amount the client pays after the deductible |
| Balance | The difference between your fee and the allowed amount, which the client pays when you have no contract |
| Out-of-pocket maximum | The cap on the client's annual cost sharing; OON costs may count toward a separate cap |
| Preauthorization | Some plans require approval for certain outpatient mental health services even out of network |
A worked example helps. If your fee is the full session rate and the plan's allowed amount is lower, the plan applies coinsurance to the allowed amount, not to your fee. The client's net reimbursement is therefore often a smaller share of what they paid than they expect.
Verify OON benefits before the first session
Whether you or the client makes the call, the same questions apply. Record the answers, the date and the representative's reference number.
- Does the plan have out-of-network benefits for outpatient mental health? Some HMO and EPO plans have none outside emergencies.
- What is the OON deductible, and how much has been met this year?
- What coinsurance applies after the deductible?
- How does the plan set the allowed amount for codes such as 90791 and 90837?
- Is preauthorization required for outpatient psychotherapy or for longer sessions?
- Are telehealth sessions covered out of network, and which place of service code is expected?
- What is the deadline for member-submitted claims?
Our eligibility verification process uses the same checklist for in-network and out-of-network clients. The answers also feed directly into the client's good faith estimate.
Option 1: superbills
With a superbill, the client pays your full fee, you give them an itemized statement with codes and identifiers, and the client sends it to their plan. Your administrative work stays low, and payment does not depend on the plan.
The trade-off is client effort. Some clients never submit, others submit with errors and assume the plan denied them. A clear handout and a consistent template reduce both problems. Our guide to the superbill for therapy includes a field-by-field template and a list of common mistakes.
Option 2: courtesy billing
Courtesy billing means the practice submits an out-of-network claim to the client's plan on the client's behalf, usually on a CMS-1500 or electronic 837P. The client may still pay at the time of service, or the practice may collect an estimated amount and bill the balance after the plan pays.
What changes when you courtesy bill
- You become responsible for clean claim data, timely submission and follow-up on denials.
- Plans may send payment to the client rather than the practice when you are out of network; set a policy for how that is handled.
- You need to post payments, reconcile EOBs and send patient statements for the remaining balance.
- Assignment of benefits forms and financial policies need to be signed before the first claim.
Courtesy billing improves the client experience, but it is real billing work. Practices that offer it should track OON claim status the same way they track in-network accounts receivable.
Option 3: single-case agreements
A single-case agreement (SCA) is a one-off contract between an out-of-network therapist and a plan to treat one specific member at an agreed rate, often at in-network cost sharing for the client. Plans typically consider an SCA when they cannot offer an in-network clinician with the right specialty, language or availability within a reasonable distance or time.
Building an SCA request
- Confirm with the plan that the member has no suitable in-network option, and document names and dates.
- Explain the clinical need: specialty, modality, continuity of care or access barriers.
- Propose a rate per CPT code and the number of sessions or the date range.
- Ask how claims should be submitted, which identifiers to use and whether authorization numbers are required.
- Get the agreement in writing before treating under it, and note its end date.
SCAs are negotiated case by case, and plan practices differ widely. Track each agreement's expiry so you can request a renewal before sessions continue without coverage.
Good faith estimates for out-of-network clients
Under the No Surprises Act, providers must give a good faith estimate to uninsured and self-pay individuals. CMS guidance describes a self-pay individual as someone enrolled in a plan who is not seeking to have a claim submitted to that plan for the service. Clients who pay you directly and file their own superbills commonly fall into that group.
If the final bill exceeds the estimate by at least $400, the client can start the federal patient-provider dispute resolution process. Recurring therapy can be covered by one estimate for up to 12 months when it describes the expected sessions. Our article on good faith estimates for therapists explains timing and required content.
When you courtesy bill a claim to the client's plan, the client is generally no longer self-pay for that service. Check current CMS guidance and your own legal advice for mixed arrangements.
Documentation and coding that support reimbursement
Out-of-network plans still review medical necessity, and some request records. Documentation standards should be the same whether or not you are contracted.
- Record start and stop times for time-based psychotherapy codes.
- Link each session to a diagnosis and a treatment plan with measurable goals.
- Use place of service 02 or 10 for telehealth as the plan requires, and note the client's location.
- Keep the CPT code on the superbill or claim consistent with the progress note.
The behavioral health billing guide covers code selection for intake, individual, family and add-on services.
Choosing the right mix for your practice
Solo clinicians with a small caseload often keep it simple with superbills. Group practices with administrative staff are more likely to offer courtesy billing as a client benefit, and practices treating a niche population may get steady SCA requests. Whatever the mix, write it into your financial policy so every client hears the same explanation.
If courtesy billing or SCA tracking is outgrowing your front desk, Fastora works with therapists and counselors on out-of-network claims, payment posting and patient statements, starting with a free billing assessment.
Checklist
Frequently asked questions
Can an out-of-network therapist bill the client for the full fee?
Generally yes, when there is no contract with the plan, because you have not agreed to the plan's allowed amount. State law, plan type and specific programs such as Medicare and Medicaid have their own rules, so check those before balance billing. Explain the fee and the likely reimbursement in writing at intake.
What is the difference between courtesy billing and a superbill?
With a superbill, the client submits the paperwork to their plan. With courtesy billing, the practice submits an out-of-network claim on the client's behalf and handles follow-up. Courtesy billing is easier for clients but adds claim work, payment posting and statements for the practice.
How long does a single-case agreement take to set up?
It varies by plan and by how quickly you can show that no suitable in-network clinician is available. Start the request before treatment if possible, keep notes of every call, and do not assume the agreed rate applies until you have it in writing.
Do out-of-network therapists need to give good faith estimates?
Federal rules require good faith estimates for uninsured clients and for insured clients who are not having a claim submitted to their plan. Many out-of-network clients who pay directly and file their own superbills fall into that group, so most private-pay practices provide them.
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