To bill or not to bill out of network benefits.

[barb2512]

Question from clinical psychologist. Does she have to abide by the out of network benefits? Can she charge and collect her regular fee and give the client a receipt which they file with the insurance and not follow the deductible and copay set by the client's out of network benefits?

[PMRNC]

Question from clinical psychologist. Does she have to abide by the out of network benefits? Can she charge and collect her regular fee and give the client a receipt which they file with the insurance and not follow the deductible and copay set by the client's out of network benefits?

As long as they do not have a contract with that payor. It's always recommended par or non par that billed charges be ONE uniform fee schedule for the provider, this does two things, it keeps accurate data for reporting and analyzing payor adjustments AND data used statistically by carriers and Medicare is accurate so that in determining fee schedule formula's accurate costs are reported to estimate these figures.  If the provider is non par they do not even have to file the claim (non govt plans) and can collect payment in full from the patient.   I have my clients try to always obtain up-front payment and either we bill as a courtesy or give the patient an itemized bill for their own submission.

[barb2512]

Thank you for your response. The counselor is out of network and the client does have out of network benefits. But if I am understanding this correctly, she does not have to use the client's out of network benefits because she is not under contract to do so.

She does charge the same as what she bills to insurance. But since insurance reprices she is paid less than her regular fee.

I appreciate you!!
Barb

[PMRNC]

So you are able to balance bill the patient.