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Out-of-Network Claims Underpaid? How a New York Pain Practice Recovered $184,000
A four-physician interventional pain management practice in Manhattan, New York deliberately remained out-of-network with most commercial health plans to preserve its fee schedule. However, despite charging its full rates, the practice was collecting only 41% of billed charges. Out-of-network claims were being processed without a structured reimbursement strategy, leaving significant revenue uncollected even though services were medically necessary and correctly performed.
When MZ Medical Billing performed a comprehensive out-of-network billing review, we found the problem extended far beyond claim submission. Incomplete superbills delayed patient reimbursements, assignment of benefits (AOB) was captured on only 54% of claims, payer-determined allowed amounts were accepted without appeal, underpayments were never reconciled, secondary insurance was rarely billed, and patient responsibility was handled inconsistently. Together, these breakdowns reduced reimbursement and created ongoing revenue leakage across the practice's entire out-of-network revenue cycle.
The review also uncovered payer-specific reimbursement issues. Deflated usual, customary, and reasonable (UCR) allowed amounts were never challenged, eligible claims were not escalated through independent dispute resolution (IDR), reimbursement checks were frequently mailed to patients instead of the practice because AOB was missing, and payment posting lacked any expected reimbursement benchmark to identify underpayments. As a result, the practice assumed low out-of-network payments were simply part of doing business.
This out-of-network billing case study explains how MZ Medical Billing rebuilt the practice's entire out-of-network revenue cycle, standardized superbills, improved AOB capture from 54% to 94%, implemented reconciliation-driven payment posting, pursued appeals and IDR on underpaid claims, activated coordination of benefits (COB), reduced the out-of-network denial rate by 74%, increased average reimbursement from 41% to 63% of billed charges, and recovered $184,000 in additional out-of-network reimbursement.
The Practice and the OON Gap
The practice is a four-physician interventional pain management group in Manhattan, New York, performing the full range of image-guided interventional procedures — epidural steroid injections, facet joint injections and medial branch blocks, radiofrequency ablation, sacroiliac joint injections, and spinal cord stimulator trials — alongside evaluation and management visits and conservative pain care. Like many interventional pain groups in high-cost markets, the practice had made a deliberate strategic choice to remain out-of-network with the majority of commercial payers rather than accept the deeply discounted in-network contracted rates those plans offered for high-RVU interventional work.
That decision only pays off if the practice has the out-of-network billing infrastructure to collect on it. This one did not. Out-of-network reimbursement is a fundamentally different discipline from in-network billing: instead of a contracted allowed amount, the payer determines its own allowed amount using a "usual, customary, and reasonable" (UCR) methodology, reimburses a percentage of that allowed amount, and leaves the rest as patient responsibility — coinsurance, deductible, and, where permitted, the balance. Every one of those steps is negotiable or appealable, and every one of them was being left on the table.
The symptoms were textbook. Superbills handed to patients for self-submission were missing the data payers needed, so patient reimbursements stalled. Where the practice billed the payer directly, assignment of benefits (AOB) was captured on barely half of claims — so reimbursement checks were mailed to patients, many of whom never forwarded them. Payers were paying against low UCR allowed amounts, and not a single one of those determinations had ever been appealed. And nobody was reconciling what was actually paid against what the claim should have reimbursed — so underpayments simply vanished into "that's just how OON pays."
Across a trailing review period, the group's blended out-of-network collection rate sat at roughly 41% of billed charges — a number the physicians assumed was simply the ceiling for OON. It was not. The practice engaged MZ Medical Billing to rebuild its out-of-network revenue cycle end to end. Our pain management billing team scoped the OON gaps and had a corrective plan in front of the partners within the first two weeks.
Six Out-of-Network Failures Bleeding Reimbursement on Every Claim
The audit examined a full review period of out-of-network claims, superbills, remittances, and patient statements. Six distinct OON-specific failures surfaced — none of them about clinical coding, all of them about the out-of-network billing mechanics the practice had never built.
Patients submitting their own OON claims were handed superbills that lacked essential elements — rendering and referring NPIs, the practice tax ID and address, correct place-of-service, itemized CPT and ICD-10 codes with modifiers, individual line charges, and the date and description of service. Payers kicked these back for missing information, and reimbursement to the patient stalled indefinitely. An incomplete superbill is not a claim — it is a delay.
Without a signed assignment of benefits directing the payer to pay the provider, out-of-network reimbursement checks are mailed to the patient. Nearly half of this practice's claims had no AOB on file — so checks went to patients, and a meaningful share of those were cashed and never forwarded to the practice. The service was delivered, the payer paid, and the money never reached the provider. This was pure, avoidable leakage.
The payer's allowed amount on an OON claim is its own determination — often built on a low percentile of a UCR database or a Medicare-multiple that bears little relationship to the actual billed charge for high-RVU interventional procedures. Every EOB showing a deflated allowed amount is an appealable determination. This practice had never appealed one. Thousands of claims had been adjudicated at low allowed amounts and simply accepted as final.
There was no benchmark for what an OON claim should reimburse and no reconciliation of ERA/EOB payments against it. Underpayments — a claim paid at 30% of billed when comparable payers were allowing far more, or a payer applying the wrong coinsurance split — were invisible because nothing was measuring them. Without an expected-reimbursement benchmark, every payment looked correct by default.
On OON claims, patient responsibility (deductible plus coinsurance against the allowed amount) is calculated differently than in-network, and the rules on billing the remaining balance depend on whether surprise-billing protections apply. The practice was inconsistent — sometimes writing off legitimate coinsurance it was entitled to collect, sometimes billing patients amounts that protection rules prohibited. Both errors carried cost: lost revenue on one side, compliance risk on the other.
Where a patient carried secondary coverage, coordination of benefits should route the primary payer's EOB to the secondary for additional reimbursement. On OON claims this can materially close the gap between allowed and billed. The practice was not identifying secondary coverage or forwarding primary EOBs, so a whole layer of legitimate reimbursement was never pursued. COB is one of the most overlooked OON revenue sources — and it was fully untapped here.
Billed, Allowed, Paid — The Three Numbers That Define an OON Claim
Every out-of-network claim lives or dies on the gap between three numbers: what the provider bills, what the payer allows, and what the payer actually pays. Understanding — and then working — each gap is the entire discipline of out-of-network billing.
The allowed amount is the fulcrum of every OON claim. Payers derive it from a usual, customary, and reasonable methodology — often a percentile of a commercial charge database, or a multiple of the Medicare fee schedule. For high-RVU interventional pain procedures, the payer's default allowed amount is frequently far below the reasonable market charge, which is precisely why it must be challenged rather than accepted.
The plan reimburses its OON coinsurance percentage — commonly 50–70% — of the allowed amount, not of the billed charge. So two levers move total reimbursement: raising the allowed amount (through appeal and documentation) and confirming the correct coinsurance tier and out-of-pocket status were applied. Both were being ignored here.
Patient responsibility on an OON claim is the OON deductible plus coinsurance calculated against the allowed amount. Whether the provider may also bill the balance between allowed and billed depends on whether balance-billing and surprise-billing protections apply. Getting this right protects both revenue and compliance — the practice had been getting it wrong in both directions.
Rebuilding the Superbill — The Document Every OON Reimbursement Starts With
For any patient submitting their own out-of-network claim, the superbill is the claim. If it is incomplete, the payer cannot adjudicate it and the patient's reimbursement stops before it starts. Fixing the superbill was the fastest, highest-yield correction in the entire engagement.
The practice's superbills read like receipts, not claims. Payers process an OON member submission only when the document contains everything a CMS-1500 would — and these were missing critical fields, so members' reimbursements were denied or pended for information the patient could not supply.
- Rendering and referring provider NPIs absent or incomplete
- Practice tax ID (EIN) and service-location address missing
- Place-of-service code omitted or incorrect for the setting
- CPT procedure codes without required modifiers and laterality
- ICD-10 diagnoses not linked to the procedures that justified them
- Per-line itemized charges collapsed into a single total
MZ rebuilt the superbill as a payer-ready, self-submission-grade document — a claim in everything but envelope. Every element a payer needs to adjudicate an OON member submission is now present and correct at the point of care.
- Complete provider identifiers — rendering NPI, referring NPI, EIN
- Correct place-of-service and full service-location detail
- Itemized CPT lines with modifiers, units, and individual charges
- Diagnosis-to-procedure linkage supporting medical necessity
- A patient submission guide explaining how and where to file
- Practice-direct billing offered wherever AOB could be captured
From Claim Submission to Payment Posting — The OON Path, Rebuilt
An out-of-network claim travels a longer, more contested path than an in-network one. Each stage below is a place where reimbursement was leaking — and each was rebuilt with an OON-specific control.
Verify the plan has out-of-network benefits, the OON deductible status, coinsurance tier, and any AOB honoring policy — before the visit, not after the denial.
Submit the clean CMS-1500 with AOB where captured, or issue a payer-ready superbill for member self-submission where it is not.
The payer sets its allowed amount via UCR, applies deductible and coinsurance, and issues the ERA/EOB — the determination to be checked, not trusted.
Post the ERA/EOB against the expected-reimbursement benchmark, flagging any variance between allowed, paid, and expected for follow-up.
Where the allowed amount is deflated or the claim underpaid, appeal with documentation — and escalate eligible claims to independent dispute resolution.
The critical shift was moving from a "submit and accept" posture to a "submit, measure, and contest" one. In-network billing can often stop at posting because the contracted rate is fixed. Out-of-network billing cannot — because the allowed amount is a payer determination, the work only begins when the ERA/EOB arrives. Rebuilding stages 3 through 5 is where the majority of the recovered reimbursement came from.
Where New York's Rules Shape Out-of-Network Billing
Out-of-network billing in New York operates inside a specific legal framework — the state's surprise-billing law and independent dispute resolution process, layered with the federal No Surprises Act. These rules define where balance billing is prohibited, where it is permitted, and how underpaid OON claims can be escalated for a binding determination.
New York was an early mover on surprise medical bills, and its framework governs a large share of what an out-of-network provider may and may not do. For genuine surprise-billing situations — emergency care, or care delivered by a non-participating provider at an in-network facility without informed patient consent — the patient is protected from balance billing, and the payment dispute between provider and plan is routed to the state's independent dispute resolution (IDR) process rather than to the patient's wallet. Knowing which claims fall under these protections is essential: billing a protected patient for the balance is both prohibited and reputationally costly, while failing to use IDR on an eligible underpaid claim leaves money unrecovered.
For the practice's elective, scheduled interventional procedures where the patient knowingly chose an out-of-network provider, the economics are different: standard OON reimbursement rules apply, patient responsibility (deductible and coinsurance against the allowed amount) is legitimately collectible, and balance billing may be permissible subject to proper disclosure and consent. The correct handling depends entirely on classifying each encounter accurately — and that classification had never been done here. Every claim was being treated the same, which meant protected patients were occasionally billed improperly and eligible claims were never escalated to dispute resolution.
The federal No Surprises Act adds a parallel layer for the claims it governs, with its own federal IDR mechanism and its own notice-and-consent requirements. For a New York interventional pain group, the practical result is a decision tree on every OON claim: is this claim surprise-protected under state law, governed by the federal NSA, or a straightforward elective OON encounter? Each path has different balance-billing rules and a different escalation route. Billing correctly for New York out-of-network providers means running that decision tree on every single claim, not applying one blanket approach.
Protects patients from balance billing in surprise situations (emergency, or OON provider at in-network facility). Payment disputes go to state IDR, not the patient.
Independent dispute resolution for eligible OON claims — a binding determination of a reasonable payment between provider and plan. Underpaid eligible claims should be escalated, not written off.
Parallel federal protections and a federal IDR mechanism for the claims it governs, with its own notice-and-consent rules for elective OON care.
Where the patient knowingly chooses OON care, standard reimbursement rules apply — deductible and coinsurance collectible, balance billing subject to disclosure and consent.
Every claim must be classified — surprise-protected, NSA-governed, or elective OON — because balance-billing rules and escalation routes differ for each.
Fighting the Allowed Amount — The Appeal Ladder That Moved Reimbursement
The single largest recovery lever in out-of-network billing is contesting the payer's allowed amount. A deflated UCR determination is not final — it is the opening position. MZ built a structured escalation ladder that took underpaid claims from the first-level appeal all the way to independent dispute resolution where eligible.
For every EOB showing a deflated UCR allowed amount, a first-level appeal was filed challenging the determination — supported by the medical necessity documentation, the complexity of the interventional procedure, and comparable reasonable-charge benchmarks for the CPT in the New York market.
Where the first level held, a second-level appeal escalated with additional clinical documentation — operative notes, imaging guidance records, and prior conservative-care history — reframing the claim around the reasonableness of the charge and the necessity of the procedure.
Eligible claims underpaid after internal appeals were escalated to New York's IDR process (or the federal NSA IDR where it governed), submitting the provider's reasonable-payment case for a binding determination — the mechanism most OON practices never use.
Every appeal and IDR outcome was logged by payer and CPT, building a reimbursement benchmark the practice now uses to spot underpayments faster and to strengthen the documentation package on the next appeal for the same procedure.
ERA, EOB, and the Expected-Reimbursement Benchmark That Made Underpayments Visible
In out-of-network billing, payment posting is not a clerical step — it is the control point where underpayments are caught or lost forever. Without a benchmark for what each claim should reimburse, an ERA/EOB showing a low payment looks identical to a correct one. Building that benchmark is what turned invisible losses into recoverable dollars.
ERAs and paper EOBs were posted as whatever the payer paid, with no comparison to an expected amount. A claim reimbursed at 30% of billed and one reimbursed at 60% were both simply "posted." Because there was no benchmark, there was no variance — and with no variance, there was nothing to appeal, follow up, or reconcile.
- Payments posted at face value, no expected-amount comparison
- Deductible and coinsurance splits accepted without verification
- Zero-pay and low-pay EOBs filed without a follow-up trigger
- Credit balances and misapplied payments never reconciled
MZ built a per-CPT, per-payer expected-reimbursement benchmark from historical OON allowed amounts and appeal outcomes, and every ERA/EOB is now posted against it. Any claim landing below its expected reimbursement is automatically flagged into the appeal queue — turning payment posting into the front line of underpayment detection.
- Every payment posted against an expected-reimbursement benchmark
- Allowed-vs-paid-vs-expected variance calculated on every claim
- Below-benchmark claims auto-routed to appeals or IDR
- Deductible / coinsurance math verified against plan benefits
- Credit balances and posting errors reconciled every cycle
Getting the Money to the Right Place — Assignment, Responsibility, and Secondary Coverage
Even a perfectly adjudicated OON claim leaks revenue if the check goes to the wrong party, the patient portion is miscalculated, or secondary coverage is never billed. These three mechanics — assignment of benefits, patient responsibility, and coordination of benefits — were rebuilt together because they govern where every dollar of OON reimbursement ends up.
A signed AOB instructs the payer to reimburse the provider directly rather than the patient. MZ moved AOB capture to the front desk as a required intake step, honored where the plan permits it, and lifted capture from 54% to 94%. For plans that do not honor AOB, the payer-ready superbill and a member-submission workflow ensure the reimbursement still gets tracked and pursued.
Patient responsibility was recalculated correctly on every claim — OON deductible plus coinsurance against the allowed amount — and collected where legitimately owed. Balance billing was applied only where permissible under New York and federal rules, with proper disclosure, and never on surprise-protected patients. The result recovered rightful revenue while removing the compliance exposure of improper balance bills.
Secondary coverage is now identified at eligibility, and the primary payer's EOB is forwarded to the secondary for additional OON reimbursement. On out-of-network claims this COB layer can meaningfully narrow the gap between allowed and billed — and for this practice it opened a reimbursement stream that had been completely dormant.
How We Rebuilt the OON Revenue Cycle Step by Step
The rebuild followed the OON claim's own path — front-end capture first, then submission, then the contest phase where the reimbursement actually lives. Each phase closed one of the six failures.
The rebuild started where OON reimbursement is won or lost — at intake. Out-of-network benefit verification (OON deductible, coinsurance tier, AOB honoring policy) became a pre-visit standard, assignment of benefits was moved to a required front-desk capture step, and the payer-ready superbill replaced the old receipt-style document for member self-submission.
- OON benefits verified before every scheduled interventional procedure
- AOB capture built into intake — 54% to 94%
- Payer-ready superbill deployed for all member self-submissions
Every OON claim was submitted clean — full charges at the practice's fee schedule, correct interventional CPT coding with modifiers and laterality, diagnosis linkage supporting medical necessity, and a surprise-billing classification (protected / NSA-governed / elective OON) assigned to route balance-billing and escalation correctly from the start.
- Full-charge, correctly coded CMS-1500 submissions with AOB where captured
- Each claim classified for surprise-billing status on submission
- Denial rate on OON submissions cut by 74%
A per-CPT, per-payer expected-reimbursement benchmark was built and every ERA/EOB posted against it. Allowed-vs-paid-vs-expected variance is now calculated on every claim, and any payment landing below benchmark is automatically flagged into the appeal queue — making underpayment detection a routine output of posting rather than a lucky catch.
- Expected-reimbursement benchmark built per CPT and per payer
- Every remittance posted with an allowed / paid / expected variance
- Below-benchmark claims auto-routed to appeals
The largest recovery phase. Deflated UCR allowed amounts were appealed at first and second level with clinical and reasonable-charge documentation, and eligible underpaid claims were escalated to New York IDR or federal NSA IDR. Every outcome fed the benchmark, compounding the strength of the next appeal for the same procedure and payer.
- First- and second-level appeals filed on deflated allowed amounts
- Eligible claims escalated to state and federal IDR
- Average payment moved from 41% to 63% of billed charges
Patient responsibility was recalculated and collected correctly, balance billing applied only where permissible with proper disclosure, and coordination of benefits activated so secondary payers were billed with the primary EOB. Together these closed the last leaks — money reaching the right party, in the right amount, from every available source.
- Patient responsibility recalculated; compliant balance billing only
- COB activated — secondary payers billed with primary EOBs
- Credit balances and misapplied payments reconciled each cycle
The Recovery, Broken Down by OON Source
The recovered $184,000 came from five distinct out-of-network revenue streams, each tied to a specific failure the rebuild closed. Every dollar traces to a concrete OON action — an appeal filed, an allowed amount raised, a check redirected, a secondary payer billed.
The Out-of-Network Position, Compared Directly
| OON Function | Before Rebuild | After Rebuild | Impact |
|---|---|---|---|
| Superbills | Receipt-style documents missing NPIs, EIN, POS, itemized charges — payers pended member submissions for information. | Payer-ready, claim-grade superbills with full identifiers, itemized CPT lines, and diagnosis linkage. | Member reimbursements stopped stalling — $34K recovered with AOB recapture |
| Assignment of Benefits | Captured on 54% of claims — payer checks routed to patients, many never forwarded. | Captured on 94% of claims at intake; superbill workflow for non-AOB plans. | Reimbursement checks now reach the provider — leakage largely closed |
| Allowed Amount / UCR | Deflated UCR allowed amounts accepted as final — zero appeals ever filed. | Systematic first- and second-level appeals; eligible claims escalated to IDR. | $68K from appeals + $46K from IDR — the core of the recovery |
| Payment Posting | ERAs/EOBs posted at face value with no expected-reimbursement benchmark. | Posted against a per-CPT, per-payer benchmark; variances auto-flagged to appeals. | Underpayments became visible and recoverable instead of invisible |
| Reimbursement Rate | Blended OON collection at 41% of billed charges — assumed to be the ceiling. | Average payment at 63% of billed charges after appeals and IDR. | A 22-point lift in realized reimbursement on out-of-network work |
| Patient Responsibility & Balance Billing | Coinsurance sometimes written off; protected patients sometimes balance-billed. | Correct deductible/coinsurance collected; balance billing only where permissible. | Rightful revenue captured and improper-balance-bill compliance risk removed |
| Coordination of Benefits | Secondary coverage never identified or billed — an entire reimbursement layer dormant. | Secondary coverage identified at eligibility; primary EOBs forwarded to secondaries. | $13K from COB and reconciliation — a previously untapped stream |
What This Engagement Proves About OON Billing
Choosing to be out-of-network is only half a strategy. The decision preserves the fee schedule, but it only produces revenue if the practice builds the OON collection machinery to go with it — superbills, AOB capture, allowed-amount appeals, and reconciliation. Without that out-of-network billing infrastructure, an OON practice simply collects whatever the payer decides to pay, which is exactly what a low in-network contract would have delivered anyway.
The allowed amount is the whole game. In out-of-network billing the payer sets its own allowed amount via UCR, and that determination is an opening position, not a final one. Practices that accept the first EOB leave the largest recoverable dollars on the table. Systematic appeals on the allowed amount — escalated to IDR where eligible — were the single biggest source of recovery in this engagement.
A superbill is a claim, and an incomplete one is a denial. When a patient self-submits an out-of-network claim, the superbill must contain everything a CMS-1500 would. Missing NPIs, EIN, place-of-service, or itemized charges don't slow reimbursement — they stop it, for information the patient cannot supply. Rebuilding the superbill was the fastest, cleanest win in the entire project.
Without assignment of benefits, the money goes to the patient. On OON claims, no AOB means the payer's check is mailed to the member — and a real fraction never reaches the provider. Moving AOB capture to a required intake step and lifting it from 54% to 94% closed one of the most avoidable leaks in out-of-network revenue.
You cannot recover an underpayment you cannot see. OON payment posting without an expected-reimbursement benchmark makes every payment look correct. Building a per-CPT, per-payer benchmark and posting every ERA/EOB against it turns underpayment detection from a lucky catch into a routine output — the precondition for appealing anything at all.
In New York, classification comes before collection. Every OON claim must be sorted — surprise-protected, NSA-governed, or elective — because balance-billing rules and escalation routes differ for each. Get it right and you collect rightful patient responsibility and escalate eligible claims to IDR; get it wrong and you either lose revenue or improperly balance-bill a protected patient. Classification is the compliance and revenue hinge of OON billing.
Questions Out-of-Network Practices Ask Most
The questions below are the ones out-of-network practices ask most about maximizing reimbursement — answered the same way we answered them for this pain management group.
Yes — that first allowed amount is a payer determination, not a contract. It is typically built on a UCR database percentile or a Medicare multiple, and for high-RVU interventional procedures it is frequently far below a reasonable market charge. A first-level appeal supported by medical necessity and reasonable-charge documentation, escalated to a second level and then to independent dispute resolution where eligible, regularly moves the paid amount upward. In this engagement, appeals and IDR together were the largest source of recovered reimbursement.
A payer-ready superbill contains everything a CMS-1500 claim would: rendering and referring provider NPIs, the practice tax ID and service-location address, the correct place-of-service code, itemized CPT procedure codes with modifiers and units, linked ICD-10 diagnoses, individual line charges, and the date of service. A receipt showing a total and a description is not enough — the payer will pend or deny the member's submission for missing information. When a patient self-submits, the superbill is the claim, so it has to be complete.
Because without it, the out-of-network reimbursement check is mailed to the patient, not the provider. A signed AOB directs the payer to pay the practice directly — where the plan honors assignment. When AOB is missing, the practice is depending on the patient to receive the check and forward it, and a meaningful share never do. Moving AOB capture to a required intake step is one of the highest-return, lowest-effort improvements an OON practice can make.
It depends entirely on the situation. For genuine surprise-billing scenarios in New York — emergency care, or an out-of-network provider at an in-network facility without informed consent — the patient is protected and cannot be balance-billed; the payment dispute goes to independent dispute resolution instead. For elective, scheduled care where the patient knowingly chose an out-of-network provider, balance billing may be permissible subject to proper disclosure and consent. Classifying each claim correctly is what keeps the practice compliant while still collecting everything it is legitimately owed.
You compare what was paid against what the claim was expected to reimburse — which means you need an expected-reimbursement benchmark per CPT and per payer, built from historical allowed amounts and appeal outcomes. Post every ERA/EOB against that benchmark and calculate the allowed-vs-paid-vs-expected variance. Anything landing below benchmark is a candidate for appeal. Without the benchmark, a low payment and a correct payment look identical, and underpayments simply disappear into the AR.
It can add a meaningful amount, and it is routinely overlooked. When a patient has secondary coverage, forwarding the primary payer's EOB to the secondary can capture additional reimbursement that narrows the gap between the allowed and billed amounts. Because many OON practices never identify secondary coverage in the first place, this layer sits completely dormant — as it did here until it was activated at eligibility and became a standing part of the workflow.
"This group made the right strategic call to stay out-of-network, and then never built the machinery to collect on it. Superbills that couldn't be reimbursed. Assignment of benefits on barely half the claims, so checks went to patients. Deflated allowed amounts accepted without a single appeal. No benchmark, so no underpayment was ever visible. And a whole coordination-of-benefits layer sitting untouched. We rebuilt the out-of-network revenue cycle from intake to IDR, and reimbursement moved from 41 cents on the billed dollar to 63 — $184,000 in additional collections the practice had assumed simply wasn't collectible."MZ Medical Billing — Out-of-Network Billing Case Summary, Pain Management, New York 2025–2026
We Were Out-of-Network on Purpose.
We Just Had No Idea How Much of It We Weren't Collecting.
We went out-of-network deliberately. The in-network rates the commercial plans offered for interventional procedures were not sustainable, so we made the call to bill out-of-network and preserve our fee schedule. What none of us understood was that being out-of-network is a completely different billing operation, and we were running it like in-network billing that just happened to get paid less.
MZ walked in and showed us things I genuinely didn't know. Our superbills — the ones we handed patients to submit themselves — were missing information the payers required, so those patients were never getting reimbursed and we never heard about it. We were capturing assignment of benefits on about half our claims, which meant insurance checks were being mailed to patients instead of us, and plenty of those never came back. And the allowed amounts — we had never appealed a single one. Not one. We just took whatever the EOB said.
They rebuilt everything. New superbills that actually work. Assignment of benefits captured at the front desk. A benchmark so they could see when a claim was underpaid, and then they appealed those — all the way to dispute resolution when it qualified. They also cleaned up how we were handling patient balances, which honestly I was nervous about from a compliance standpoint.
The number that stuck with me: we went from collecting 41% of billed to 63%, and they recovered $184,000 we had basically written off as "that's just OON." I don't think of out-of-network as leaving money on the table anymore — because now we actually collect it.
Is Your Out-of-Network Revenue Actually Reaching Your Practice?
Incomplete superbills, missing assignment of benefits, unappealed allowed amounts, and unreconciled underpayments quietly cap what an out-of-network practice collects. MZ Medical Billing's out-of-network medical billing team rebuilds the full OON revenue cycle — superbills, AOB, claim submission, reconciliation-driven posting, and appeals through IDR — so you collect what your out-of-network decision was supposed to earn.
Schedule a Free Out-of-Network Billing Review