BILLING PT'S VS INSURANCE

[srob48]

HI Everybody,
  We are a billing company, and we have one physician in particular that is a specialist and has to give injections to over 70% of his pt's daily. His reimbursement is terrible on these injections, they average around $.44 vs his cost for a vial of $35.00. He is wanting to implement a policy that he bill the pt for these injections and we not bill their insurance. I have researched this and have really not found anything that really talks about this, but, with my 20 years as a coder I really don't feel he can do this. His office manager has tried to explain this to him but he isn't hearing it. He feels he should be able to do this since he isn't billing the insurance AND the pt. If anybody out there knows the answer to this or a place I can go that will explain it so I can give him the facts as to why he can't that would be GREATLY appreciated. But if he can do this that would be WONDERFUL!!! So, please, please if anybody knows please reply!


Thank you!
Sherry

[PMRNC]

In a nutshell, no, if he participates with insurance companies he doesn't get to pick/choose what he bills them vs. the patient.  What he CAN do however which might solve his problem is to have patients sign something that they will pay for these injections if the carrier doesn't cover them. Now this doesn't mean he gets to charge for the full fee if the carrier "allows" the participating allowable rate, he cannot, he can only charge up to the allowable on it. Not sure how you would iterate this to him since he's "Not hearing it".  When I encounter a client unwilling to change or abide by the rules he's told I won't bill anything I know to be questionable, and that would qualify. I would further explain to him that even as an "employee", your liability is the same as his and our not willing to risk it.

[srob48]

Thank you so much for replying so quickly and giving me that answer that is just what I needed! I hate his reimbursement isn't any better than what he is getting, but, then again he has to play by the rules!



Thank you so much!
Sherry

[srob48]

If anybody else has any information please let me know because he is still wanting "proof" of this, some doctors can be so hard headed at times! Its like I and his office manager are banging our heads against the wall with this!

[PMRNC]

The proof is in his provider contracts. Tell him to pull them out and read them.