Out-of-Network Medical Billing Services for Nevada Providers
Out-of-network claims pay more, but only when they're billed, negotiated, and followed up correctly. We verify OON benefits before the visit, submit clean claims, secure single case agreements, and fight underpayments, under both the federal No Surprises Act and Nevada's surprise billing law.
Since 2014
Billing Nevada practices
BAA signed
Before any PHI
4–5%
of net collections
No setup fee
60-day exit
What is out-of-network
medical billing?
Out-of-network medical billing is the process of billing a patient's health plan when the provider has no contract with that plan. Without a contract, there's no fixed fee schedule. The plan decides an allowed amount using its own method, such as usual, customary, and reasonable (UCR) rates, a percentage of Medicare, or a negotiated agreement. The patient's share depends on their plan's out-of-network benefits.
That makes every OON claim a small negotiation. Getting paid well means knowing the patient's benefits before the visit, documenting medical necessity, choosing the right payment route, and pushing back when the allowed amount is too low.
In-network vs.
out-of-network billing
| In-network billing | Out-of-network billing | |
|---|---|---|
| Payer contract | Signed contract with set rates | No contract |
| How payment is set | Contracted fee schedule | Plan's allowed amount (UCR, % of Medicare, QPA) or a negotiated agreement |
| Typical reimbursement | Predictable, often lower | Often higher, but varies by plan and claim |
| Patient cost share | In-network copay, coinsurance, deductible | OON deductible and coinsurance, unless federal or Nevada surprise billing protections apply |
| Who gets the payment | Usually the practice | The practice, or sometimes the patient, depending on the plan and assignment of benefits |
| Balance billing | Not allowed | Allowed only where federal and state law permit it |
| Admin work | Lower | Higher: benefits checks, negotiation, appeals |
Do out-of-network providers need to enroll with payers?
With commercial plans, no. There's no "out-of-network enrollment": being out of network simply means you have no contract with the plan. You do need a payer-recognized identity before claims will pay:
- An NPI and tax ID on every claim, matching your W-9.
- A payer provider record which some commercial plans create when they receive your first claim, and others require you to register for in their portal.
- EFT and ERA setup so payments arrive by direct deposit with electronic remittance, not by paper check or a virtual card with processing fees.
Government payers work differently:
- Medicare: you must enroll through PECOS to bill Medicare, even as a non-participating provider. The only alternative is to opt out and use private contracts.
- Nevada Medicaid and its managed care plans: these generally pay only providers enrolled with Nevada Medicaid, even for out-of-network services such as emergencies or single case agreements.
We set up each of these before your first OON claim goes out. If you later decide to join a network, our medical credentialing services handle the contracting.
How out-of-network billing
works for patients
Out-of-network billing affects your patients as much as your practice. Their OON deductible and coinsurance usually apply, some plans send the payment to them, and they may owe the balance where the law allows it. Practices handle this in one of two ways:
| Courtesy billing | Superbill (patient files the claim) | |
|---|---|---|
| Who files the claim | Your practice, on the patient's behalf | The patient, using a superbill you provide |
| When the patient pays | Their share after the plan pays | Usually your full fee at the visit |
| Who gets reimbursed | Your practice (with assignment of benefits) or the patient | The patient |
| Best for | Higher-cost care, facilities, and programs | Private-pay therapy and concierge practices |
We run either model, and give patients a clear estimate of their share before care begins.
See what your OON claims should be paying
Signs your out-of-network
claims are losing money
Allowed amounts that look arbitrary.
Payers price OON claims through repricing vendors and benchmarks, and first offers are often low.
Checks going to patients instead of your practice.
Some plans pay the member directly on OON claims, and that money rarely reaches you without follow-up.
HMO and EPO denials.
These plans usually have no OON benefits unless you secure a network gap exception or a single case agreement.
No Surprises Act deadlines missed.
If you don't open negotiation within 30 business days of a payment, you lose the right to dispute it.
Patients surprised by their share.
Unclear estimates lead to unpaid balances and bad reviews.
Who we help in OON
Billing Services
We bill out-of-network claims for Nevada providers who stay out of network by choice, and for those who are out of network because they aren't contracted yet:
- Therapists, psychologists, and psychiatrists in private practice
- Behavioral health and substance use disorder programs: IOP, PHP, residential, and detox
- ABA, TMS, and Spravato providers
- Surgeons, ambulatory surgery centers, and anesthesia groups
- Emergency, urgent care, laboratory, and imaging providers
- Concierge, functional medicine, and specialty clinics
- New practices billing while credentialing is still in progress
Our out-of-network billing services
for healthcare providers in Nevada (NV)
Every service below is part of one workflow, so nothing falls between a benefits check and a final payment.
OON benefits verification
Before the first visit, we confirm the patient's out-of-network deductible, coinsurance, out-of-pocket maximum, visit limits, and prior authorization rules. We also confirm the plan's pricing method, so you know what to expect before you treat.
Patient cost estimates and Good Faith Estimates
We prepare clear estimates of the patient's share. For uninsured and self-pay patients, we prepare the Good Faith Estimate the No Surprises Act requires.
Claim and superbill preparation
We code each visit with CPT, HCPCS, and ICD-10-CM codes and the right modifiers. We submit professional claims on the CMS-1500 and facility claims on the UB-04. For patients who file their own claims, we produce superbills that payers accept the first time.
Single case agreements and gap exceptions
When a patient's plan has no OON benefits, or no in-network provider can deliver the care, we request a network gap exception or negotiate a single case agreement (SCA) at an agreed rate before care begins.
Pre-service and post-payment negotiation
We negotiate rates before high-value services, and we push back on low allowed amounts after payment, including offers from repricing vendors.
No Surprises Act open negotiation and IDR
For claims the federal law covers, we track every deadline, open negotiation within 30 business days, and prepare and file federal independent dispute resolution (IDR) cases when negotiation fails.
Nevada surprise billing arbitration
For medically necessary emergency services under Nevada's state-regulated plans, we follow the dispute process in NRS 439B.700–439B.760.
Underpayment recovery and appeals
We compare each payment against the expected allowed amount and appeal underpayments and denials with medical necessity documentation, all the way through second-level and external review.
Payment posting and reconciliation
We post every OON payment from the ERA or EOB, reconcile it against the expected amount, and flag virtual card payments with fees so you can request ACH or check instead.
Payments sent to patients
When a plan pays the member instead of your practice, we document the payment, follow up with the patient, and update assignment-of-benefits forms to reduce repeats.
Patient balance billing
Where the law allows it, we bill the patient's remaining share with clear statements, payment plans, and polite follow-up.
Monthly OON Billing Reporting
Each month, you get OON collections, allowed amount as a percentage of billed charges, open negotiations, IDR outcomes, and AR by payer.
What a payer-ready superbill includes
A superbill missing one element gets rejected or paid low. Ours include:
- Patient: name, date of birth, address, and insurance member ID.
- Provider: name, credentials, individual and group NPI, tax ID, license number, and practice address and phone.
- Service: date of service, place-of-service code, CPT or HCPCS codes with modifiers and units, and the charge for each line.
- Diagnosis: ICD-10-CM codes linked to each service.
- Payment: amount the patient paid, and the provider's signature.
For example, a therapy superbill might list psychotherapy code 90837 (60 minutes) with diagnosis code F41.1 (generalized anxiety disorder).
Setting your out-of-network fee schedule
Your charges set the ceiling on every OON payment, since plans that pay a percentage of billed charges or UCR can't pay more than you bill. We help you set a fee schedule from geographic benchmarks, such as FAIR Health percentiles and Medicare multiples. We also make sure you charge every payer the same usual fee, which protects you in negotiations and audits.
How plans price
out-of-network claims
Knowing the pricing method is half the negotiation. These are the methods we see most:
| Pricing method | How it works | What we do |
|---|---|---|
| Usual, customary, and reasonable (UCR) | A percentile of charges in your geographic area, often from benchmark databases such as FAIR Health | Check the percentile and area used, and appeal when they're wrong |
| Percentage of Medicare | The plan pays a set multiple of the Medicare fee schedule | Confirm the multiple in the patient's plan documents |
| Percentage of billed charges | The plan pays part of your full charge | Make sure your chargemaster is set correctly |
| Repricing vendor offer | A third party proposes a discounted rate | Counter or reject offers below fair value, before you sign |
| Qualifying payment amount (QPA) | The plan's median in-network rate, used for claims the No Surprises Act covers | Open negotiation, then IDR if needed |
| Single case agreement | A negotiated rate for one patient's course of care | Negotiate it in writing before treatment |
How our out-of-network
billing process works
- 1
Check benefits.
We verify OON coverage, the pricing method, and authorization rules before the visit.
- 2
Set the payment route.
We decide whether to bill OON benefits directly, request a gap exception, negotiate an SCA, or prepare a Good Faith Estimate.
- 3
Code and submit.
We submit clean claims within 24 hours of receiving documentation.
- 4
Review every payment.
We compare the allowed amount with what the claim should pay, and flag underpayments.
- 5
Negotiate, appeal, or dispute.
We use the right route for each claim: an appeal, open negotiation, federal IDR, or Nevada arbitration.
- 6
Close out the balance.
We bill the patient's share where it's allowed, and report results to you every month.
Find out what your out-of-network claims are leaving behind
The No Surprises Act
and out-of-network providers
The federal No Surprises Act took effect on January 1, 2022. It protects patients with private health coverage from surprise bills in three situations:
Emergency services,
at out-of-network facilities or from out-of-network providers.
Non-emergency services from out-of-network providers at in-network facilities,
such as hospitals, hospital outpatient departments, critical access hospitals, and ambulatory surgery centers.
Air ambulance services
from out-of-network providers. Ground ambulance services aren't covered.
In these situations, the patient pays only their in-network cost share, and the provider can't balance bill them for the rest. The provider's payment is settled with the plan instead.
Notice and consent. For some non-emergency services at in-network facilities, an OON provider may balance bill if the patient signs a written notice and consent form in advance: at least 72 hours before the service, or 3 hours before for same-day appointments. This exception isn't available for ancillary services, including emergency medicine, anesthesiology, pathology, radiology, neonatology, assistant surgeons, hospitalists, intensivists, and laboratory services.
The payment dispute timeline:
- 1
The plan must send an initial payment or a notice of denial within 30 calendar days of receiving a clean claim.
- 2
The provider has 30 business days from that payment or denial to start open negotiation.
- 3
If negotiation doesn't settle the claim within 30 business days, either side has 4 business days to start federal independent dispute resolution (IDR).
- 4
A certified IDR entity picks either the provider's offer or the plan's offer, considering the QPA and other factors.
Missing any of these deadlines can forfeit your right to a higher payment. We track them for every eligible claim.
Uninsured and self-pay patients. Providers must give these patients a Good Faith Estimate. If the final bill is $400 or more above the estimate, the patient can start a patient-provider dispute.
Nevada's surprise billing law
Nevada protected patients before the federal law did. Assembly Bill 469 (2019), codified at NRS 439B.700–439B.760, covers medically necessary emergency services from out-of-network providers. Patients pay no more than their in-network copayment, coinsurance, or deductible, and payment disputes between the provider and the plan go to state arbitration.
Which law applies depends on the patient's plan: Nevada's law for state-regulated plans, and the federal process for others, such as self-funded employer plans. Before filing any dispute, we confirm which process governs the claim, so it isn't rejected for going to the wrong forum.
Medicare and Nevada Medicaid
The No Surprises Act doesn't govern Medicare or Medicaid. Each has its own rules:
- Medicare non-participating providers may charge up to the limiting charge, 115% of the non-participating fee schedule amount, on unassigned claims.
- Providers who opt out of Medicare bill patients directly under a private contract, and Medicare pays nothing.
- Nevada Medicaid providers generally can't balance bill Medicaid patients.
We'll tell you exactly which rules apply to each of your patients.
Not sure whether federal or Nevada law covers your claims?
Out-of-network billing
by Healthcare specialty
Behavioral health and SUD programs
IOP, PHP, residential, and detox programs depend on SCAs, concurrent reviews, and UB-04 facility billing.
Therapists and psychiatrists OON Billing
Private-pay practices need superbills, OON benefit checks, and patient reimbursement support.
ABA, TMS, and Spravato Out of Network Billing
These services depend on authorization limits and, often, gap exceptions.
OON Billing for Hospital-based and surgical providers
These providers are the most affected by the No Surprises Act, so open negotiation and IDR matter most here.
Do you need special software
for out-of-network billing?
No single software package solves out-of-network billing. Software can scrub claims and track AR, but the money comes from the work around it: checking OON benefits, picking the right payment route, negotiating, and meeting dispute deadlines. We work inside your current EHR or practice management system, including DrChrono and eClinicalWorks, and track every OON claim through to resolution.
Our OON Billing Pricing
Out-of-network billing is included in our standard plans, at 4–5% of net collections, with no setup fee and a 60-day exit. Programs with heavy facility billing, or large IDR volumes, are priced on our Enterprise plan.
Our commitments
Claims submitted within 24 hours of receiving documentation.
Every No Surprises Act deadline is tracked, from initial payment through open negotiation and IDR.
Every denial and underpayment worked within 5 business days.
Compliant patient billing. We never balance bill where federal or Nevada law forbids it, and we don't routinely waive patient cost share, a practice payers can treat as fraud.
BAA signed before we see any patient data.
See HIPAA compliance →Out-of-network billing FAQs
Can't find what you need? Our Nevada team answers every question before you commit.
They're services that bill a patient's health plan when your practice has no contract with it. They include OON benefits checks, claim submission, rate negotiation, single case agreements, appeals, No Surprises Act disputes, and patient balance billing where it's allowed.
Often, yes. Without a contracted fee schedule, OON allowed amounts can exceed in-network rates. Payments vary widely, though, and low first offers are common, so negotiation and appeals make the difference.
It depends on the service and the plan. Balance billing isn't allowed for emergency services, or for most non-emergency services from OON providers at in-network facilities, under the No Surprises Act and Nevada's AB 469. In other situations, such as a planned visit to an OON private practice, the patient may owe the difference.
It applies to providers, facilities, and air ambulance companies treating patients who have private health coverage, including employer and individual plans. It doesn't apply to Medicare, Medicaid, or other federal programs, which have their own protections.
Independent dispute resolution is the No Surprises Act's arbitration process. If open negotiation fails, a certified IDR entity chooses either the provider's or the plan's payment offer. The deadlines are strict, so we track each one.
A single case agreement (SCA) is a one-time contract between an out-of-network provider and a plan, covering one patient's care at an agreed rate. It's common when no in-network provider can offer the needed care.
Not with commercial plans; out of network means no contract. You still need an NPI, tax ID, and EFT/ERA setup, and some plans require portal registration. Medicare requires PECOS enrollment even for non-participating providers, and Nevada Medicaid generally pays only enrolled providers.
With courtesy billing, your practice files the OON claim for the patient. With a superbill, the patient pays you and files the claim themselves. Courtesy billing usually collects more for the practice; superbills are simpler for private-pay therapy practices.
Some plans pay the member directly on OON claims, even with an assignment of benefits on file. We track these payments, follow up with patients, and help reduce how often it happens.
Yes. We bill for non-participating Medicare providers, applying the limiting charge rules. If you've opted out of Medicare, Medicare claims aren't filed, and we help you manage private contracts and patient billing instead.
There's no single best tool. Your EHR or practice management system handles claims; the results come from benefits checks, negotiation, and dispute deadlines. We work inside the system you already use.
OON billing is included in our plans at 4–5% of net collections, with no setup fee. Facility programs and high IDR volumes are priced on our Enterprise plan.
Keep exploring
Find out what your out-of-network claims should be paying
Send us 90 days of OON claims. We'll show you where allowed amounts fall short, which claims still qualify for negotiation or IDR, and what you could recover. You get a written report within 5 business days, at no cost.
Please don't include patient information. We sign a BAA before reviewing any claim data.