Client filing out of network claims and expecting provider to honor discount

[barb2512]

Provider is are out of network with optum and not filing the claims for the client- 90837 self pay fee of $150, but we are in network with multiplan, who processes this particular employers plan, Client position -she files the claims herself, than all she should have to pay at the office is the discounted amount of 104.20 for the visits. whether or not she files the claims is her point

but my position is
that she agreed to a self pay fee and unless she provides us with an eob (like she did for the three visits on the document she sent) than we are not obligated to give her a discount.
if she files the claims and presents the explanation of benefits showing the discount then we will credit her the 45.80 per appt.
my position is that providers in network status does not apply unless she files the claims. if she doesn't file the claims than the self pay fee applies.

any thoughts appreciated. b.

[Michele]

I'm a little confused.  Are you with the provider's office? 

If provider is out of network with the insurance carrier then they can charge the regular fee for the service, they do not have to honor a discount. Multiplan is not an insurance carrier, but a network of providers.  Does the provider have a contract with Multiplan?  If the provider signed a contract with Multiplan then they would need to refer to the contract to see if they must honor the discount.

[barb2512]

Thank you. That does help. Appreciate your time. b.