Author Topic: Billing Insurance two different rates  (Read 5941 times)

barb2512

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Billing Insurance two different rates
« on: September 23, 2014, 06:58:15 PM »
Depending- If a client is paying for visits which will be charged against their deductible the provider is setting the fee per appt at $80 so that only $80 will be charged as the client's responsibility because that is all the client can afford. Then when the client meets her deductible the counselor charges her regular fee of $150 for a 90834. The insurance will reprice the claim and the client will owe her copay.

This doesn't look kosher to me. Any thoughts?

Thank you,
Barbara

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Re: Billing Insurance two different rates
« Reply #1 on: September 23, 2014, 07:03:40 PM »
Quote
Depending- If a client is paying for visits which will be charged against their deductible the provider is setting the fee per appt at $80 so that only $80 will be charged as the client's responsibility because that is all the client can afford. Then when the client meets her deductible the counselor charges her regular fee of $150 for a 90834. The insurance will reprice the claim and the client will owe her copay.

This doesn't look kosher to me. Any thoughts?

You had me until you said: 
Quote
The insurance will reprice the claim and the client will owe her copay.

To answer this simply.. THE provider best be charging the rate they are collecting. If they are Charging $80, the insurance should be billed $80 showing patient payment if they paid, if they try and bill the regular rate of $150 when doctor is only taking $80 that's absolutely wrong. The insurance company has to be billed the same amount as the patient is billed. The out of pocket is the out of pocket, the patient has to pay the full out of pocket (coinsurance) no matter what.
You can also check with the plan and see if they have deductible carryover months for Oct/Nov/Dec   many plans still have those.

I am not sure what you meant by insurance will reprice..they won't go back ..but the patient is still going to be responsible for the coinsurance/copay/deductible up to either the fee schedule (if par) or up to U&C if non par.
Linda Walker
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barb2512

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Re: Billing Insurance two different rates
« Reply #2 on: September 23, 2014, 08:10:45 PM »
I am sorry if I wasn't clear.

Client's paying $80 an appt and insurance is getting billed $80 an appt until client meets deductible.

After deductible is met client is paying copay and counselor is billing insurance $125 an appt.

b.

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Re: Billing Insurance two different rates
« Reply #3 on: September 23, 2014, 09:10:14 PM »
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I am sorry if I wasn't clear.

Client's paying $80 an appt and insurance is getting billed $80 an appt until client meets deductible.

After deductible is met client is paying copay and counselor is billing insurance $125 an appt.

This seems OK..But I would tend to really think about this.. and unless you have an office policy that makes this UNIFORM across the board, you could run into trouble later... Despite what people believe.. non govt payors DO indeed scrutinize providers and WILL flag certain things. A drastic change in fees COULD be a red flag.    Your office financial policy that all patients receive should be uniform and this way all patients are treated equally, you take risk of a carrier red flagging you for fee schedule billing changes.. that COULD be problem.. it's NOT illegal as long as you are billing the same fee to insurance carrier as you are the patient..but it COULD be a problem if the provider is making all kinds of different concessions. If you have another patient who has NO deductible but on same plan, the provider could be red flagged..   It's a crap shoot.
Linda Walker
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barb2512

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Re: Billing Insurance two different rates
« Reply #4 on: September 23, 2014, 09:51:41 PM »
Thank you!! I appreciate all the feedback. Have been going back and forth on it. Uniformity is definitely the way to go on it.

Barbara

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Re: Billing Insurance two different rates
« Reply #4 on: September 23, 2014, 09:51:41 PM »

kristin

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Re: Billing Insurance two different rates
« Reply #5 on: September 23, 2014, 10:18:42 PM »
I wouldn't let this happen, personally. The provider really should not be changing the amounts she bills to a particular insurance company, because she is telling them that she is willing to go below her average fee of $125, by sending in some claims for $80. Definite red flag. She has to pick a fee, and stick with it, for everyone with that insurance.

What would make more sense is if she bills her regular fee all the time, and has the patient fill out financial hardship paperwork so she can legally reduce the bill down, after the insurance processes the claim.

barb2512

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Re: Billing Insurance two different rates
« Reply #6 on: September 29, 2014, 02:28:52 PM »
I would like to know more about the financial hardship paperwork. Specifically if it is listed in the law somewhere so I can give that to the counselor. Please let me know where to look for that online. Thank you.
Barbara

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Re: Billing Insurance two different rates
« Reply #7 on: September 29, 2014, 03:39:54 PM »
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I would like to know more about the financial hardship paperwork. Specifically if it is listed in the law somewhere so I can give that to the counselor. Please let me know where to look for that online. Thank you.

Physicians offices should and can come up with their own UNIFORM policy on hardships. The law is clear on fraud/abuse, anti-kickback, etc.. "CANNOT ROUTINELY" waive/discount. With that said each practice needs to review their office policies and depending on geographical locations, poverty levels, etc come up with ONE policy and stick with it.
Linda Walker
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RichardP

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Re: Billing Insurance two different rates
« Reply #8 on: September 29, 2014, 04:43:50 PM »
I would like to know more about the financial hardship paperwork. Specifically if it is listed in the law somewhere so I can give that to the counselor.

Google on "MEDICAL PATIENT" + "FINANCIAL HARDSHIP"  (include the quotes)

You will find much information down that path.  See also the following link.  Your questions are discussed starting at Page 32, middle of page.

http://www.donself.com/documents/Billing-Compliance-Manual.pdf

Barb - having said that - we've had this discussion before.  You can get a sense of what the larger discussion is about by reading my comment at the following link.  But you can gain some useful perspective if you read the entire thread.

http://www.medicalbillinglive.com/members/index.php?topic=7116.msg21514#msg21514

Here is a condensed version of my point at that link.  This gives some larger context to the questions you are asking:

... price discrimination by physicians and hospitals is legal.  The Robinson–Patman Act of 1936, an amendment to the Clayton Antitrust Act, prohibits price discrimination - but only for commodities.  It does not prohibit price discrimination for services.  And hospitals and insurance companies and doctors do engage in price discrimination - all quite legally.  For those interested in more information, Google on "price discrimination" + healthcare (or 'doctors').

... there is no law that says a doctor or hospital has to charge the same fee (and publish a list of fees) for the same service to every patient.  Google and read as I recommended above and you will see that this is not just my opinion.

Even though the law allows a doctor and a hospital to charge whatever they want to whomever they want (for services rendered), this freedom is constrained in certain circumstances.  And Billergirlnyc points to some areas where these constraints might kick in; e.g., a doctor's contract with an insurance carrrier (including Medicaid and Medicare), HIPAA and ACA requirements, and any state regulations.  But these regulations only constrain price discrimination in pre-defined circumstances - they don't prohibit price discrimination in all circumstances.  Therefore, it is to a doctor's benefit to consult with a health-care attorney who knows which state and Federal regulations will constrain that particular doctor's practice.
« Last Edit: September 29, 2014, 04:47:30 PM by RichardP »

barb2512

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Re: Billing Insurance two different rates
« Reply #9 on: September 29, 2014, 09:16:18 PM »
Thank you very much. I look forward to reading your article.

Barbara

Medical Billing Forum

Re: Billing Insurance two different rates
« Reply #9 on: September 29, 2014, 09:16:18 PM »

kristin

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Re: Billing Insurance two different rates
« Reply #10 on: September 29, 2014, 10:29:04 PM »
Some further information:

http://www.physicianspractice.com/blog/addressing-patient-financial-hardship-your-medical-practice

As Richard said, Googling the search terms he listed will give you a lot of info, and various forms other offices use.

Another option is to set up a payment plan with the patient, if they don't qualify for financial hardship.

As Linda said, and I agree, the doctor should have a uniform financial policy in place for patients to sign, and it should be adhered to.

barb2512

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Re: Billing Insurance two different rates
« Reply #11 on: September 30, 2014, 11:22:12 AM »
Thank you. That is a good point, that Medicare only allows for billing of the patient, not the patient's parent. I appreciate the response. It helps me think through the counselor's reasoning as well as my own.
Barbara

Medical Billing Forum

Re: Billing Insurance two different rates
« Reply #11 on: September 30, 2014, 11:22:12 AM »