Non-participating providers
Out-of-Network Billing Handled by People Who Do It Daily
Specialist handling for out-of-network claims, No Surprises Act disputes and single case agreement negotiation.
The short version
Out-of-Network (OON) Billing without the guesswork
Out-of-network billing follows different rules, and applying in-network habits to it reliably produces underpayment. There is no contracted rate to fall back on, reimbursement is benchmarked rather than fixed, and since the No Surprises Act a large share of disputes now runs through a formal arbitration process with strict deadlines.
We handle OON claims as their own discipline: correctly constructed claims, documented assignment of benefits, benchmark evidence to support the charge, and confident use of the open negotiation and IDR pathways when a payer determination falls short.
Why this matters
Where out-of-network revenue disappears
OON claims fail in ways in-network claims never do, and most billing teams have simply never had to learn the difference.
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Payment sent to the patient
Without a valid assignment of benefits on file, the payer pays the member directly and the practice is chasing a patient for the full amount.
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Allowed amounts accepted without challenge
An OON determination is an opening position, not a fee schedule. Accepting it as final leaves negotiable money on the table.
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Open negotiation window missed
The No Surprises Act sets a 30-business-day open negotiation period. Letting it lapse closes the route to arbitration entirely.
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No benchmark evidence
An appeal that asserts a charge is reasonable without supporting market data gives the payer nothing to move against.
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Balance billing rules misapplied
Getting the protected-service rules wrong exposes the practice to compliance risk as well as to unrecoverable balances.
Scope of work
What OON support covers
Everything below is in scope from day one. Nothing here is an upsell later.
OON claim construction
Claims built with the documentation, disclosures and consent records that non-participating claims require.
No Surprises Act compliance
Notice and consent handling, protected-service identification and correct treatment of patient cost-sharing.
Benchmark analysis
Charges supported with recognized market data so a negotiating position rests on evidence rather than assertion.
Open negotiation and IDR
We initiate open negotiation, and where it fails, prepare and submit the independent dispute resolution package.
Single case agreements
Case-by-case rate agreements negotiated in advance for high-value or continuing-care episodes.
Assignment of benefits
AOB collection and enforcement so payment reaches the practice rather than the patient mailbox.
Workflow
How we work an OON claim
The same sequence runs every day, which is what makes the output predictable.
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1
Coverage and benefit analysis
We establish the patient out-of-network benefit level and whether the service falls under protected-service rules.
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2
Consent and disclosure
Where notice and consent applies, documentation is completed correctly before the service is delivered.
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3
Single case agreement check
For planned high-value episodes we attempt a rate agreement up front rather than arguing after the fact.
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4
Claim submission
The claim goes out with assignment of benefits, supporting documentation and the correct charge basis.
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5
Determination review
The payer allowed amount is compared against benchmark data to judge whether it is worth challenging.
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6
Open negotiation
We open the statutory negotiation period with a documented counter-position and supporting evidence.
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7
IDR submission
If negotiation fails inside the window, we compile and file the dispute resolution package before the deadline.
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8
Patient communication
Patients are kept informed throughout, because OON episodes generate the most anxious billing questions.
Questions
About Out-of-Network (OON) Billing
What practices usually want to know before handing this part of the revenue cycle over.
Ask us something elseYes, but it now requires process discipline. The Act constrained balance billing for certain protected services and created a formal dispute route. Practices that use that route properly can still be reimbursed fairly.
It is a one-off contracted rate for a specific patient episode, negotiated before care where possible. It is worth pursuing for planned, high-value or continuing care, where certainty is worth more than an argument later.
We do. That includes eligibility assessment, certified IDR entity selection, the offer and supporting documentation, and tracking against the statutory deadlines, which are unforgiving.
How it works
How working with us actually starts
No long implementation project, no switching systems. Four steps, and most practices are live inside a month.
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01
Revenue assessment
We audit a sample of your claims, denials and aged A/R and show you what we found. Free, and yours to keep either way.
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02
Scope and agreement
A written scope covering exactly which services we run, what it costs and what we are accountable for.
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03
Access and onboarding
We set up inside your existing EHR and clearinghouse. Two to four weeks, run in parallel with your current process.
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04
Live and reporting
We take over submission and follow-up, and you get monthly reporting you can actually act on.
Free consultation
Want a read on your out-of-network billing?
We will review a sample of your claims and come back with what we found. No cost, no commitment, and the findings are yours regardless of what you decide.