Out-of-network billing has always been a point of tension between behavioral health providers and insurance companies. Even when services are covered, providers often find themselves reimbursed at rates far below what is reasonable or sustainable. These reduced payments not only jeopardize the financial stability of practices but also make it harder to maintain consistent, high-quality care for clients who desperately need support.

Payers know this system well, and, in many cases, they rely on the fact that providers won’t have the time or resources to challenge unfair reimbursement. But the truth is, behavioral health organizations have options. By understanding why reimbursements are so low and by implementing effective strategies to fight back, you can improve financial outcomes and secure the revenue your services are worth.

Why Out-of-Network Reimbursement Is So Low

Insurance companies are in the business of minimizing costs, and out-of-network claims are often viewed as a financial liability. To justify paying less, payers may reference outdated “usual and customary” rates, apply internal benchmarks that don’t reflect the current market, or use payment algorithms that consistently undervalue behavioral health services.

Behavioral health providers are especially vulnerable because treatment often requires multiple sessions per week, ongoing therapy, or longer-term programs like IOP or residential care. When reimbursement is slashed, these models of care become financially difficult to sustain. Without consistent advocacy, low out-of-network reimbursement risks becoming the industry standard, leaving providers underfunded and clients underserved.

Recognizing these dynamics is the first step toward change. By identifying how payers reduce reimbursement, you can develop targeted strategies to push back and protect your practice.

Tip 1: Review the Explanation of Benefits (EOB) Carefully

The Explanation of Benefits (EOB) is more than just a receipt for services—it’s a roadmap to understanding how payers calculate reimbursement. Unfortunately, many providers give EOBs a quick glance without digging into the details. That’s where hidden issues can slip through. Underpayments, incorrect application of deductibles, or even coding errors may be buried in the fine print.

Taking the time to review each EOB carefully can reveal patterns and provide leverage for disputes. For example, if you notice a payer consistently reimburses below a certain percentage of billed charges, you can begin documenting this trend. Over time, these records create a strong case for systematic underpayment, which can be used in appeals or even in discussions with regulatory agencies.

Instead of viewing EOBs as an afterthought, treat them as a critical part of your revenue cycle. Every line item tells a story, and sometimes that story is the key to fighting back against unfair practices.

Tip 2: Know and Use Your State’s Laws

Many providers don’t realize that state laws can work in their favor. Some states require insurers to pay “usual and customary rates,” which means reimbursement must align with fair market benchmarks rather than arbitrary numbers chosen by the payer. Other states have surprise billing laws or independent arbitration processes that allow providers to dispute unfair payments.

For behavioral health organizations, understanding these laws can be a game-changer. Referencing a specific statute in your appeal letter immediately strengthens your case and demonstrates that you know your rights. Educating patients about these laws can also empower them to challenge their insurance carriers directly, creating additional pressure on payers to act fairly.

If you’re unsure what protections exist in your state, consult with a billing advocate like Integrity Billing. Knowing the legal framework in which you operate ensures you’re not leaving money on the table simply because you weren’t aware of your options.

Tip 3: File Strong Appeals

When faced with low reimbursement, an appeal is often your best defense. However, the strength of your appeal makes all the difference. A vague request for reconsideration is unlikely to succeed; instead, appeals should be detailed, evidence-based, and persistent.

A strong appeal includes documentation of medical necessity, comparative data showing what other payers reimburse for similar services, and references to state or federal laws when applicable. For example, including benchmark data from sources like FAIR Health can highlight the discrepancy between the payer’s rate and fair market value.

Persistence is equally important. Many payers initially deny appeals in hopes that providers will give up. By following up, resubmitting when necessary, and maintaining thorough records of communication, you demonstrate that you won’t accept underpayment as the norm. Over time, this persistence can lead to more favorable outcomes.

Tip 4: Strengthen Documentation and Coding

Low reimbursement doesn’t always stem from payer practices. Sometimes, incomplete documentation or coding issues open the door for reduced payments. Insurance companies will seize on any opportunity to argue that services weren’t medically necessary or properly supported.

To protect yourself, ensure that every service is coded accurately and that your documentation is airtight. Progress notes should clearly demonstrate why the service was provided, how it supports the treatment plan, and the outcomes being achieved. Treatment plans should be updated regularly and reflect measurable goals. The stronger your documentation, the less room payers have to dispute your claim.

In addition, proper coding helps ensure you are billing at the highest appropriate level. Many providers unintentionally leave revenue on the table by under-coding or failing to use modifiers correctly. Regular staff training and coding audits can help identify these gaps and maximize your reimbursement potential.

Tip 5: Partner with an Experienced Billing Advocate

Fighting low reimbursement is time-intensive, and most behavioral health providers already have full plates caring for clients and managing operations. This is where a billing partner becomes invaluable. Experienced billing advocates know payer tactics, understand the regulations, and have proven strategies for filing successful appeals.

At Integrity Billing, we monitor claims from submission to payment, identify underpayments, and challenge them on your behalf. Our team tracks industry trends, leverages legal frameworks, and uses data to make sure you get paid fairly for the services you provide. By taking this burden off your shoulders, we free you to focus on your clients.

Partnering with experts also ensures consistency. Instead of fighting payer battles sporadically, you’ll have a systematic process in place to challenge unfair practices and secure more predictable cash flow.

Securing Fair Payment for the Care You Provide

Low out-of-network reimbursement is a frustrating reality, but it doesn’t have to be accepted as inevitable. By carefully reviewing EOBs, leveraging state laws, filing strong appeals, tightening documentation and coding, and partnering with a dedicated billing advocate, you can push back against payer tactics and secure the reimbursement your services deserve.

At Integrity Billing, we believe behavioral health providers should never have to compromise quality care because of inadequate payment. With the right strategies and support, you can protect the financial health of your organization. Give us a call today at 800-683-5640 or fill out our contact form to learn more about our billing services.