Hi Oliver! Good news!

Ensora is capable of managing both in-network and out-of-network claims. The Provider must be able to convey the requirements of the Payer regarding the taxonomy number and/or the service code for in-network versus out-of-network claims. This information is essential to ensure that the Insurers are properly configured within Ensora. With the information, we can help! 

To expound on this, here is our knowledge article on the topic as well:

https://support.ensorahealth.com/s/article/360052148252-Submit-Out-of-Network-Claims-TheraNest

Thank you for reaching out! We will speak soon!

Thank you so much for your response and for confirming that Ensora can manage both in-network and out-of-network claims. That’s great news.

I just wanted to clarify one key point: when you say Ensora can “manage” out-of-network claims, does that include full-service billing support—specifically the entire claim cycle such as submission, tracking, denial follow-up, resubmission, appeals, and accounts receivable management until payment is complete? If so what would this service cost?

From what I’ve read on your site and from general industry standards, some billing services provide full revenue cycle management (RCM), including aggressive follow-up on unpaid or denied claims, while others provide the software platform and limited follow-up support. I want to confirm whether Ensora’s Managed Billing or RCM team performs these full-service functions for out-of-network claims as well, or if that level of follow-up is limited to in-network billing.

This will help me determine whether I need to bring in an external billing service that can handle everything end-to-end.

Thank you again for your help and for sharing the article—much appreciated!

Warm regards,
Oliver Olwyn, LCSW

Hi there!  I wouldn't be able to speak to the level of aggressiveness in pursuing claim resolution. 

However, our RCM Team does have key performance metrics to meet and are managed very closely.

The best detailed list of task/service offering as it pertains to RCM is listed here:
https://ensorahealth.com/pricing/rcm/

This way you can review and notate any service gaps that might be handled by a billing company or third party biller in conjunction with the software.

For example, the software has an authorizations feature that tracks and has a report -- but the RCM Team Member would not act as a Utilization Manager.

The claims category, whether out of network or in network should not come into play unless you receive communication from the Payer that a different rate should be used etc. These are contractual matters between the provider and the payer that would have to be disclosed to the RCM Team.

The Provider and the RCM Team -or- the Provider's third party biller and the RCM Team would definitely collaborate as a partnership in resolving unpaid items.

Thank you!