Staying Independent...Together

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   RE: asking payment and NOT billing insurance even if we're contracted
 From: Kathy Saradarian
 To: Member Forum
 Posted: 08-08-2017 08:42
 Message: 1.  I have to agree with Jeff although I haven't read my contracts in years.  My memory of my contracts is they are all about payment and contracted fees.  That is what the contract is.  You are not allowed to charge more than the contracted fee schedule, you can not collect directly from the patient anything other than their copay and then only what the insurance company says they are responsible for.  You can not balance bill.  I would be shocked if your contracts don't mention payment.  I don't know what else they would mention.  (well other than those quality indicators and time to wait for appt, etc)

2.  This one is trickier.  All participating and non-participating physicians must bill Medicare electronically.  Only those who opt out, or who do even have an option to opt-in are excluded from this (like your partner).  But patients can't bill Medicare to my knowledge.   And you can't bill a secondary without the rejection from the primary.   If this is a supplemental plan, it won't be covered.  But if it's a secondary insurance, like from a spouse or retirement plan, it should be billable, except for that little problem that you can't get a rejection from Medicare.  I'm wondering what your partner's school teaches about how to handle this.

On another issue, Melissa, my daughter is on the path to become a naturopath.  She is applying to schools this fall.  She would love to be able to "talk" with your partner about what it's like to be a practicing naturopath, especially in a state that has one of the least restrictive licenses and allows insurance participation.  Also, with you on how it fits in with allopathic medicine.

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Kathleen Saradarian, MD
Branchville, NJ
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Original Message:
Sent: 08-05-2017 12:11
From: Melissa Weakland
Subject: asking payment and NOT billing insurance even if we're contracted

Two different situations both related to collecting payment at the time of service and not billing insurance for a patient visit even though we are contracted with a particular insurance.

It seems like an area of many opinions but no consensus if I'm breaking any rules.
I can't find anything in my actual insurance contracts addressing this.

1. a non-established patient calls and needs an urgent same day appointment (a friend of patient, relation from out of town etc). They do have insurance with whom we contract but aren't planning to establish care with us. Is there anything wrong with us not collecting their insurance information and charging a one time out of pocket fee for the visit?   We provide them with claim information if requested if they want to bill the insurance on their own.

2.  A patient with medicare.  I am contracted with medicare and bill them. My partner is not contracted and cannot bill them. He is a naturopath and given a federal insurance system, they do not recognize his license.  When anyone establishes at our clinic with medicare, they sign a form and it clearly states that for visits with me I bill, but visits with Jonathan, they will have to pay out of pocket.

A patient has  a secondary that Jonathan can bill to.  Are we obligated to do the extra work to bill to that insurance for visits with him or can we still ask a patient to pay for out of pocket? They could of course still submit on their own if they so desire.


I'd also love to hear if you have a creative systems you're using to be able to continue to take insurance for the sake of our patients but make it less onerous within your own system.  That is really all we're trying to do-  find middle ground and be creative to keep it working for us all.

Thanks. Melissa

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Melissa Weakland MD
Ballard Neighborhood Doctors
Seattle WA
IMP since 2007
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