Author Topic: Client thinks out of network deductible is too high  (Read 1322 times)

barb2512

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Client thinks out of network deductible is too high
« on: March 19, 2014, 06:02:59 PM »
So she asked the counselor to accept a lower amount and asked me, counselor's biller, to send a letter to Magellan explaining that the client decided not to use her out of network benefits and wants the claims taken off her record. Magellan says they will not remove the claims unless services were not provided on that day or the provider was in network so the claims processed incorrectly. Neither of these two apply. So the counselor is just considering that we have done our due diligence to give the client what she wants and she is accepting the lower self pay fee with out the claims being removed from the record. Now the counselor is explaining to her Aetna out of network client's that they can pay her less if they do not use their out of network benefits and wants me to write to Aetna and ask to have some claims removed from patient's records.

This is turning into a circus. I know it feels wrong but I can't quite explain why to the counselor. After all, the client should be able to decide they do not wish to use their insurance. And counselors do not always collect the deductible owed to them.

Any thoughts?

Barbara

HeidiK

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Re: Client thinks out of network deductible is too high
« Reply #1 on: March 19, 2014, 08:46:41 PM »
Hi Barbara!  When I read your question I remembered an article I read about this very subject.  Obviously, there are many things to consider such as the provider's contract with various carriers and individual state law but it's a start to show you are ready to have a conversation!  Good luck!

http://managemypractice.com/download-this-form-for-patients-who-opt-out-of-using-their-insurance/

Heidi Kollmorgen, CCS-P
Heidi Kollmorgen, CCS-P
AHIMA Approved ICD-10 Trainer
hdmedicalcoding.com

PMRNC

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Re: Client thinks out of network deductible is too high
« Reply #2 on: March 20, 2014, 10:19:31 AM »
Quote
So she asked the counselor to accept a lower amount and asked me, counselor's biller, to send a letter to Magellan explaining that the client decided not to use her out of network benefits and wants the claims taken off her record. Magellan says they will not remove the claims unless services were not provided on that day or the provider was in network so the claims processed incorrectly.

A patient does indeed have the right NOT to have claims submitted to their insurance company (even if provider has contract). ONCE claims are sent.. too late, tough cookies. The patient should have done an opt out of insurance billing BEFORE the visit. (for the future you can use the Medicare ABN and remove the word Medicare). 

Ok, that's one issue.

Next the second issue is waiving/reducing patient copays. There are so many articles , laws, blah blah that I feel it a waste of MY time to explain this to a client when they should know this. And it certainly should be in their policies and procedures as well as in their office financial policies. YOU cannot routinely waive copay's and patient out of pocket for a few reasons. 1)it's illegal  2) violates patient's cost sharing provision of THEIR contract with the insurance company and 3) if you reduce patient out of pocket the insurance carrier deserves same discount so we went round and round. You reduce copay from $20 to $10 on a $100 charge , you don't have a hardship arrangement with patient, you must show the $10 discount you gave on the claim.

Quote
Neither of these two apply. So the counselor is just considering that we have done our due diligence to give the client what she wants and she is accepting the lower self pay fee with out the claims being removed from the record.

I take this to mean the counselor does not have a policies and procedures in the office nor a financial policy to refer to. That's what they are for so that us billers don't have to explain the obvious to them over and over again.

Another point to ponder.. if they continue this practice and you now know about it you become just as libel. I suggest going through the office financial/policies and procedures and coming up with ONE plan across the board and using financial hardship cases to document the true hardship cases so that it's not "routinely waiving /reducing out of pocket"   
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

barb2512

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Re: Client thinks out of network deductible is too high
« Reply #3 on: May 07, 2014, 07:36:52 PM »
Thank you. I will ask for a copy of the new client paperwork and see what she has.
I appreciate your responses.
Barbara