Billing insurance can be one of the most intimidating aspects of running a private practice, especially when treating out-of-state clients. On top of an already complicated insurance system, healthcare providers must navigate the intricacies of out-of-state billing, including out-of-state Medicaid billing, billing out-of-state Medicare, and managing out-of-network scenarios. Improperly handling the nuances of these processes can significantly impact revenue flow and the client experience. To make these processes more digestible, we have broken down what you need to know to successfully manage out-of-state billing in multiple scenarios, from eligibility verification to claim submission strategies. 

Out-of-network versus out-of-state

Clinicians may assume that treating an out-of-state client automatically means they are out-of-network—but that’s not always the case. Out-of-network refers to whether a clinician is included in a client's insurance plan, while out-of-state simply means the clinician is located in a different state than the client. This is true for both in-person services as well as telehealth. 

With the rise of telehealth and multi-state licensure, more clinicians are expanding their reach beyond their home state. If you're licensed in multiple states and credentialed with an insurance company that operates nationally, you may still be considered in-network for clients with out-of-state health insurance. However, the specific rules vary by payer, so always verify coverage details before an appointment.

Want to learn more about becoming a multi-state clinician? Check out our guide on multi-state licensure to see how expanding your telehealth services out-of-state can expand your reach and increase your practice revenue. 

Can you bill out-of-state clients?

Providing care for clients with out-of-state insurance can be complex, especially when it comes to insurance billing. If you’re licensed to practice in multiple states, you may be able to treat clients across state lines—but billing policies differ depending on private insurance, Medicare, and Medicaid. Understanding these distinctions is essential for avoiding claim denials and ensuring proper reimbursement.

Private Insurance

For private insurance plans, out-of-state insurance billing depends on the patient’s specific policy and the insurer’s network coverage. Many large insurance companies operate across multiple states, meaning you may still be considered in-network for an out-of-state client if you’re credentialed with that payer.

Medicare & Medicaid considerations for out-of-state care

For Medicare, clinicians who are enrolled in the program can typically bill for services delivered to out-of-state clients as long as they accept Medicare assignment and the care meets coverage criteria. However, reimbursement rates may differ by location, so it’s important to check with the client’s Medicare Administrative Contractor (MAC) for guidance.

For Medicaid, billing across state lines is much more restrictive. Each state administers its own Medicaid program, and most do not allow clinicians from another state to bill unless there is a specific agreement in place. Some states offer reciprocity or temporary enrollment options for out-of-state clinicians, particularly in cases of emergency care or specialized services. Before treating a Medicaid client from another state, verify if out-of-state billing is permitted and whether pre-authorization is required. 

Navigating these complexities can be challenging, and can present time-consuming tasks for administrators. To streamline this process, it is important to have effective workflows in place for various out-of-state billing scenarios. Using a comprehensive billing platform, like Healthie, can automate complex workflows to save time and reduce mistakes. 

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How do I bill as an out-of-network provider?

Billing as an out-of-network provider involves a series of steps to ensure proper reimbursement for the services rendered. When treating clients who fall outside of your network, it's essential to communicate clearly about potential out-of-pocket costs. 

1. Verification Process: Start by verifying the client's insurance information and coverage, including any out-of-network benefits. Modern billing and practice management solutions, such as Healthie, can perform eligibility checks prior to appointments, alerting your office to any gaps in client coverage. 
2. Discuss Financial Responsibility: Address the potential costs with clients before they are incurred, and therefore avoid surprising bills. Prompt and accurate communication with the client about their financial responsibilities, and any potential denials from their insurance, is essential when it comes to billing out-of-state clients. This will help to ensure you are reasonably compensated for your work.
3. Submitting to Insurance: When clients choose to continue with your services despite being out-of-network, you will likely still be submitting their claims to their insurance company. Submitting a claim with appropriate billing codes for the services provided is crucial – this includes using the appropriate codes for out-of-network services. Timely filing of claims and ensuring all necessary documentation is complete is equally important to ensure successful reimbursement. 
4. Provide Payment Solutions: If you’re frequently out-of-network for clients, you might consider offering different payment solutions, such as flexible payment plans to break up costs, sliding scale fees in cases of financial hardship, or membership or subscription models for ongoing care. 

How do you explain out-of-network benefits to clients?

Clients are understandingly concerned about the costs associated with seeing an out-of-network clinician, so it is important to use clear and transparent communication. Using simple, non-technical language, explain the difference in coverage between in-network and out-of-network services. Highlight the advantages and disadvantages, discussing co-pays, deductibles, and potential reimbursement rates. It's crucial to assist clients in understanding the possible financial implications and help them make informed decisions about their care. 

Insurance Billing & Healthie

Healthie offers a comprehensive platform with robust tools and features designed to assist clinicians in billing, including managing out-of-state billing and overall insurance processes. Healthie's billing tools facilitate efficient and accurate submission of claims, including support for out-of-state Medicaid billing and billing out-of-state Medicare clients.

The Healthie platform streamlines the billing workflow, aiding in compliance with diverse state regulations and ensuring accurate submission of claims for out-of-state clients. Healthie's user-friendly interface simplifies the process of verifying insurance information, submitting claims with appropriate coding, and tracking claim status.

Moreover, Healthie provides resources and support to help clinicians navigate the complex landscape of out-of-state billing, ensuring compliance with regulations and optimizing reimbursement.