Medical Billing Forum
Billing => Billing => : AdvancedSpine August 13, 2014, 01:02:39 PM
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I have a patient who has major medical and he gave us his card so we can start charging his insurance now that the PIP benefits are exhausted. We belong to the network. The doctor, for obvious reasons, does not want me to bill the health insurance and wants to wait for the LOP settlement. I want to know if he is obligated to bill the patient's health insurance? I need to make sure of this before I press to bill. Thanks
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Do you want the doctor to bill the patient's health insurance for charges already paid for by the PIP benefits - so the doctor gets paid twice?
Do you want the doctor to bill the patient's health insurance for charges that will / might be paid under the LOP (Letters of Protection?) settlement - so the doctor gets paid twice?
If that is not what you want, how can you know what to bill the health insurance for, before the LOP settlement is made? Serious question, as I can't really tell what you are thinking from the information you provided.
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My understanding is that the Med Pay (PIP) is exhausted, but the patient continues to need treatment and would like his health insurance to be billed. The patient will still be responsible for deductibles and co-pays. BUT since the doctor is in network he will have to take the network reduction instead of getting the PIP rate (sometimes it's 100% of the billed amount).
It's really a crap shoot. The doctor may collect NOTHING at the end of the claim if he waits for the settlement. He may have to take a reduction on his bill if there's a limited settlement. My personal feeling (and a "feeling" isn't always business savvy, but I have plenty of experience here) is that he should bill the health insurance and get paid for his services timely. The health insurance may not even pay since there is an open auto claim.
I do think (but I don't know the laws of your state) that the doctor is obligated to take the health insurance since he is contracted.
We are running into more and more auto insurance med pay plans that are "excess" only med pay contracts. They have to bill their health insurance, and the auto insurance will pay the co-pays and deductibles.
There are a lot of variables here. What was signed at the beginning of the claim will probably carry the most weight. LOP?
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It also really depends on the LOP itself. I'm assuming since there is a settlement pending that the LOP was already received and entered?
There is also ROR to consider.. Right of Recovery.. insurance carriers will be reimbursed if settlement takes place for treatment and services. I'm not sure the provider really should be "holding" claims because he wants to.