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asking payment and NOT billing insurance even if we're contracted

  • 1.  asking payment and NOT billing insurance even if we're contracted

    Posted 08-05-2017 09:12
    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

    Melissa Weakland MD
    Ballard Neighborhood Doctors
    Seattle WA
    IMP since 2007

  • 2.  RE: asking payment and NOT billing insurance even if we're contracted

    Posted 08-06-2017 07:32
    1 If you have a contract with  payer you have to  use it yes?I mean what if the patietn did  come to you to establish then hated you and  never came back? All the sameNo you  have a contract  so you cannot charge some onetime fee
    2 I dunno

     3 there is no easy way except not to take insurance Insurance sucks
    Again  though, I tell you, I have a biller     I do not  see most of this    I  spot check  things I wonder about( did we get paid for X,and I will follow through some things )  I look at eobs sometimes mostly I refuse ,it upsets me.  I tally in my head what I should take in and translate it to annual income In general MORE comes in that I think will.     All this stuff does is cause  agitata   Does anyone really really think docs are DOING this minutia? I talk to docs who say Z00.00 and do not  list the hypothyroidism etc for the prev. exam  i t  is too much trouble
    I  am  not going to leave money on  t he table- I  do bill for the stoopid 3.00 urinalysis ( THIS WEEK MY U/A CANISTER AND MY PREGNANCY TESTS WERE STOLEN  FROM MY OFFICE) but frankly I cu tmy losses Bill for stuff see another patient and move on. I am sometimes going to bat for things Other times I am thinking it is not worth 100.00 to  wrangle t o get 35.00
    I long ago stopped  billing for FOBT cards I lose money if I do them   I lose more  money if I bill

         Jean Antonucci MD
         115 Mt Blue Circle
         Farmington ME 04938
    ph 207 778 3313   fax 207 778 3544

  • 3.  RE: asking payment and NOT billing insurance even if we're contracted

    Posted 08-06-2017 12:54
    It depends.

    For both, I'd recommend you collect at TOS and give them info to submit.  Here's why:

    1. If your #1 patient is assigned to another primary, you might not get paid for the visit.  What if they have wrong ins info, etc?  Give them a superbill  and let them wrestle with THEIR insurance co.
    2. Since MCR doesn't cover the visit at all, the secondary could balk.  If the patient submits directly they don't have to say anything about MCR. (Other ins is primary.)
    3. Naturopaths??

    Peter Liepmann MD FAAFP MBA
    My mission is to fix US health care
    Bakersfield CA

  • 4.  RE: asking payment and NOT billing insurance even if we're contracted

    Posted 08-07-2017 19:20
    I see it as:

    1. You have a contract with the payer, so you have to bill according to the terms of that contract. Whether the patient plans to establish care is not relevant to the contract (unless you have a really atypical contract).
    2. He does not have a contract with Medicare, so he does not have a contract with the secondary payer (i.e a payer covering the patient's 20% of the Medicare Part A or B charges). He can bill however he wants, including not submitting anything to a secondary payer.

    I have no idea if I'm right; that's just how I see it.

    Jeff Huotari, M.D.
    BlueSky Health
    138 W. Highland Rd., Suite 950
    Howell, MI 48843

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  • 5.  RE: asking payment and NOT billing insurance even if we're contracted

    Posted 08-08-2017 05:42
    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.

    Kathleen Saradarian, MD
    Branchville, NJ

  • 6.  RE: asking payment and NOT billing insurance even if we're contracted

    Posted 08-10-2017 13:25
    Hi everyone.
    I am so sorry have been so distant.
    I am feeling so overwhelmed.

    But I did want to chime in on this thread.
    I have read all my contracts since I just opened in Feb. & they all allow for what is termed “non-covered service fee” can be collected from patients.
    I did call all my provider reps. and clarified this.
    So read your contracts for you may be able to collect an annual fee in addition to accepting the contracted insurer rates.

    Cindi Croft, DO