As a private practice clinician, conversations around insurance coverage are probably part of your daily routine, especially when clients are seeing you out-of-network. While it can feel like a maze of codes, deductibles, and confusing jargon, having a strong understanding of out-of-network benefits can set you apart from other clinicians and help your clients unlock greater access to more affordable care.

What are out-of-network benefits?

Out-of-network (OON) benefits refer to the insurance coverage a client can still receive when they see a provider not directly contracted with their insurance plan. These benefits are most commonly included in PPO (Preferred Provider Organization) plans, which offer more flexibility than HMOs (Health Maintenance Organization).

For private practice clinicians, this means you can still see clients whose insurance you don't formally accept—and they may still receive partial reimbursement from their insurer. Understanding how these benefits work can make your services more accessible to potential clients and also provide clients with more financial clarity. 

Do all PPO plans have out-of-network benefits?

While PPO plans are designed to include out-of-network options, not all PPO plans offer the same level of coverage. Some cover a percentage of your fee, while others may only reimburse after the client meets a deductible.

How to help clients:
Encourage clients to call their insurance company to verify coverage of OON clinicians or run their insurance information through a benefits verification tool. The information you want to obtain is:

• Whether their plan includes OON benefits
• What their out-of-network deductible is
• The percentage of services that will be reimbursed
• Whether a superbill or pre-authorization is required

Helping clients understand these details upfront ensures they can make informed decisions about their care and prevents unexpected costs down the line.

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What is the difference between out-of-network and non-participating?

It’s easy to get these two terms confused, so here’s a helpful distinction you can explain to clients:

• Out-of-network providers are not contracted with a client’s insurance but may still allow clients to submit claims for partial reimbursement.
• Non-participating providers do not accept any insurance and may be excluded entirely from a plan’s reimbursement policies.

→ Pro Tip: Always clarify your status with the client’s specific plan. For example, a clinician may be “non-participating” with Medicare but “out-of-network” for a commercial PPO. 

How to explain out-of-network benefits to clients

Navigating insurance can be overwhelming for clients. When discussing OON benefits, clear communication is essential. Use plain language, offer actionable steps, and give them space to make a decision once they have all of the information.

Here are some helpful strategies:

Provide real-life scenarios

Explain when clients might use OON benefits, such as:

• When a specialist they need isn’t in-network
• When they prefer to continue seeing a trusted clinician (like you)
• During a move, travel, or transitional period between insurance plans

Emphasize flexibility and freedom

Clients often don’t realize they can choose clinicians that are outside their network. Highlight the potential advantages:

• More control over who they see
• Greater access to niche or specialized services
• Shorter wait times

Clarify financial responsibilities before treatment

Let them know:

• OON services may involve higher deductibles and co-pays
• They may need to pay upfront and get reimbursed
• You can provide a superbill to support their claims

While having these conversations with potential clients might feel somewhat repetitive or time-consuming, it could be a differentiating factor between you and other clinicians, and result in a long-term clinician-client relationship. 

Helping OON clients make the most of their insurance benefits

Once a client knows they have out-of-network coverage, how do you help them use it effectively?

Here’s where your support and systems can make a big difference.

1. Verify insurance coverage before the appointment

Don’t wait until a bill gets denied. EHR and practice management tools like Healthie enable clinicians to automate benefits verification ahead of time.

With these tools, your admin team can:

• Confirm if OON benefits exist
• Spot coverage gaps or high deductibles
• Alert clients in advance of any potential out-of-pocket costs

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Offering this kind of proactive communication builds trust and improves retention—especially in private practice settings where clients are more involved in their healthcare decisions.

2. Help clients understand the reimbursement process

Clients are often intimidated by the idea of submitting insurance claims. You can lay out simple next steps:

• Provide a superbill that includes ICD-10 and CPT codes, clinician info, and service details
• Share a sample reimbursement form from their insurer’s website
• Explain the timeline: some insurers reimburse within weeks, others may take 30–60 days
  

2. Empower them with planning tools

Educate clients on how to budget and plan for OON costs:

• Provide fee transparency
• Offer Good Faith Estimates
• Encourage use of HSA or FSA funds where applicable

While offering this support may take some time at first, it will soon become a seamless part of your workflow—requiring minimal effort as you become increasingly familiar with various plans and build it into your routine.

Simplifying out-of-network benefits for clients

As a private practice clinician, you’re not just delivering care—you’re building relationships and managing a business. Helping clients understand and utilize their out-of-network benefits:

• Improves access to your services
• Increases the likelihood of full payment
• Builds client trust and loyalty

Tools like Healthie make it easier to integrate verifying insurance coverage, eligibility checks, superbill generation, and automated billing into your practice—all in one easy-to-use platform.