The reimbursement your patient sees, and what it does to your price

How much does a superbill pay back?

The plan pays a share of its own allowed amount for the service, after any deductible it applies to out-of-network care. The allowed amount is the ceiling a plan will pay for a covered service, and a provider may bill the patient the balance above it 1Ref 1HealthCare.gov (Centers for Medicare & Medicaid Services) (2026).Allowed Amount.Definition of the allowed amount as the ceiling a plan will pay for a covered service, and the fact that a provider may bill the patient the balance above it.. Out-of-network coinsurance is the percentage of that allowed amount the patient owes to a provider the plan has no contract with, and it usually costs more than the in-network percentage 2Ref 2HealthCare.gov (Centers for Medicare & Medicaid Services) (2026).Out-of-network coinsurance.Definition of out-of-network coinsurance as a percentage of the allowed amount owed to a non-contracted provider, and that it usually costs more than in-network coinsurance..

Washington's insurance regulator, defining terms the industry uses everywhere, calls a deductible the amount owed before the plan starts paying claims, and coinsurance an arrangement in which the insured person and the insurance company share losses in agreed proportion 3Ref 3Washington State Office of the Insurance Commissioner (2026).Glossary of Insurance Terms.A state regulator's plain-language definitions of deductible and coinsurance, and of the usual, customary and reasonable rate as tied to the going geographic rate for identical or similar services rather than to a specific provider's charge.. Run in that order, a superbill returns nothing until the out-of-network deductible is behind the patient, and after that it returns the plan's share of a ceiling you did not set.

State law sits on top of the federal frame, and it varies. What a plan sold in your state must cover, how quickly it must pay a member's claim, and which balance-billing protections attach are state questions, and your state insurance department's consumer pages are where the state answer is written as the rule for your state instead of somebody else's.

No percentage travels between plans. Two patients in the same waiting room, same code, same fee, can be owed different amounts by their own insurers, and neither number is a fact about your practice.

Where the allowed amount comes from

It comes from the going rate in a geographic area. Washington's regulator defines a usual, customary and reasonable rate as one consistent with the going rate or charge in a certain geographical area for identical or similar services 3Ref 3Washington State Office of the Insurance Commissioner (2026).Glossary of Insurance Terms.A state regulator's plain-language definitions of deductible and coinsurance, and of the usual, customary and reasonable rate as tied to the going geographic rate for identical or similar services rather than to a specific provider's charge., which measures the market around you rather than the price on your own fee schedule. Two clinicians a mile apart billing the same code at different prices meet the same ceiling.

Federal rule treats the two figures as separate objects. Plans and issuers must publicly post a machine-readable file disclosing unique out-of-network allowed amounts and billed charges for each provider by NPI, TIN and place of service, refreshed monthly across a rolling 90-day claims window 4Ref 4U.S. Department of Health and Human Services, Department of Labor, and Department of the Treasury (2024).45 CFR §147.212 — Transparency in Coverage—Requirements for Public Disclosure.The federal requirement that plans publicly post unique out-of-network allowed amounts and billed charges as separate per-provider figures, refreshed monthly over a rolling 90-day window, and the de minimis exclusion for combinations involving fewer than 20 claims.. The billed charge is yours and the allowed amount is theirs, and the file tracks them apart because they are two different quantities.

But the file will usually not contain you. A plan may leave out a provider and service combination when it involves fewer than 20 different claims 4Ref 4U.S. Department of Health and Human Services, Department of Labor, and Department of the Treasury (2024).45 CFR §147.212 — Transparency in Coverage—Requirements for Public Disclosure.The federal requirement that plans publicly post unique out-of-network allowed amounts and billed charges as separate per-provider figures, refreshed monthly over a rolling 90-day window, and the de minimis exclusion for combinations involving fewer than 20 claims., which is a threshold a solo caseload clears for very few codes with any single plan, so your own figure likely will not appear in any public disclosure. It has to come from the plan the patient is enrolled in.

Do the federal surprise-billing rules cover this visit?

They do not. 45 CFR 149.410, the balance-billing protection written for emergency care, covers emergency services furnished at a hospital emergency department or an independent freestanding emergency department 5Ref 5U.S. Department of Health and Human Services, Department of Labor, and Department of the Treasury (2024).45 CFR §149.410 — Balance Billing in Cases of Emergency Services.The scope of the federal balance-billing and cost-sharing protections to emergency services at a hospital emergency department or independent freestanding emergency department, supporting only the negative claim that a chosen out-of-network office visit falls outside them.. A patient who chose an out-of-network solo clinician for a scheduled appointment sits outside that fact pattern, so nothing in the section caps the difference between your fee and the plan's allowed amount.

That is the question underneath most of the worry about superbills. The protection attaches to the emergency department. A visit the patient sought out, paid for at the time of service and submitted for reimbursement afterward is a different transaction, and the balance above the plan's ceiling stays with them 1Ref 1HealthCare.gov (Centers for Medicare & Medicaid Services) (2026).Allowed Amount.Definition of the allowed amount as the ceiling a plan will pay for a covered service, and the fact that a provider may bill the patient the balance above it..

But state balance-billing statutes are their own layer, and their reach is a state-by-state question rather than a federal one. Read your own state's act before deciding what to tell patients, because these statutes name the settings they cover, and a solo outpatient office is either in that list or it is not.

Get the number from the plan document before you quote a price

The plan document is the one place the answer is required to appear. An ERISA plan's Summary Plan Description must state whether, and under what circumstances, coverage is provided for out-of-network services, and it must separately identify the circumstances that can cause denial, loss, forfeiture, suspension, offset or reduction of a benefit a participant might otherwise expect 6Ref 6U.S. Department of Labor, Employee Benefits Security Administration (2024).29 CFR §2520.102-3 — Contents of Summary Plan Description.The ERISA requirement that a Summary Plan Description state whether, and under what circumstances, out-of-network coverage is provided, and separately identify circumstances causing denial, loss, forfeiture, suspension, offset or reduction of an expected benefit.. An out-of-network deductible and a coinsurance split live in those two paragraphs.

That rule reaches employer-sponsored plans governed by ERISA. A policy bought on the individual market is not one, and the same questions go to that plan's own benefit documents. Either way, ask for the document instead of a summary spoken over the phone, because a document can be re-read six months later when a claim comes back reduced.

Four numbers decide what comes back, and no two of them come from the same place.

The choice between an invoice and a superbill for out-of-network patients is a separate decision from what the superbill pays, and so is what to include on a superbill, which decides whether the claim is processed at all. Ask the patient to collect those four answers before the first visit, and put both figures in writing at intake: what they pay you, and what their plan may send back to them.

What this does to your price

Once the ceiling is fixed, your fee moves the patient's cost close to dollar for dollar. The plan's payment is a percentage of its own allowed amount, so raising a fee that already sits above that amount adds nothing to what the plan sends and adds the whole increase to what the patient carries. Below the ceiling the arithmetic is gentler, because plans commonly pay against the lower of the charge and the ceiling.

That convention is worth confirming in the plan's own language instead of assuming it, and it is the reason the operative number in a pricing decision is the patient's net cost after reimbursement rather than your gross fee.

So the trade here is not the usual one, where you raise the price, lose some patients, and hope the remaining volume clears the difference. A fee increase above the ceiling lands entirely on the patient's side of the ledger, and it lands hardest on the patients whose out-of-network deductible is still unmet, because those patients are getting nothing back yet at any price.

That gap is where payment plans get asked about, since the patient pays you in full on the day and then waits weeks for their plan to return a share of a smaller number.

Run it for one representative patient before changing a price: your fee, the plan's ceiling, the deductible still unmet, the coinsurance split, and what lands back in their account. The output is their net cost, and that is the figure they compare against the practice across town.

The part the patient never gets back

Some of the gap is permanent, and the tax code recovers less of it than patients expect. IRS Publication 502 allows a deduction only for unreimbursed medical and dental expenses above 7.5% of adjusted gross income, and only on Schedule A for a taxpayer who itemizes 7Ref 7Internal Revenue Service (2025).Publication 502, Medical and Dental Expenses.The itemized-deduction threshold that only unreimbursed medical and dental expenses above 7.5% of adjusted gross income are deductible, and only for a taxpayer who itemizes.. For a patient taking the standard deduction, the unreimbursed balance is simply a cost.

So the deduction is not a rebate on the gap, and quoting it at the point of sale is a claim about somebody else's return. A patient who asks whether the difference is deductible is asking about their own adjusted gross income and their own decision to itemize, and that question belongs with whoever prepares it.

What you can say at intake is what you know: your fee, the plan's own ceiling as the figure reimbursement runs against, and the balance above it staying with the patient. The rest is a question for their plan, and their plan is required to have written the answer down.