Medical Billing Forum

Billing => Facility Billing => Topic started by: Angie on October 26, 2011, 07:45:31 AM

Title: Mental Health Billing
Post by: Angie on October 26, 2011, 07:45:31 AM
If a non participating Residential Treatment Facility for Mental Health gets an authorization from an insurance company to cover x amount of days and then they deny after so many days; Can the facility have an insurance rate that they bill the insurance (400.00 a day) and then once the insurance stops funding and it goes to strictly private pay, can they charge the patient a less amount (300.00) due to discounts they offer for no insurance coverage?
Can they have an insurance rate and then a private pay rate after the insurance will no longer fund?
Title: Re: Mental Health Billing
Post by: Michele on October 27, 2011, 08:45:30 AM
You are not supposed to charge a different rate for insurance patients than you are for self pay.  There are ways to offer discounts, etc but you need to make sure you are not breaking any state or local laws.
Title: Re: Mental Health Billing
Post by: Angie on October 27, 2011, 10:56:53 AM
Even though the daily rate is $400.00 in the contract and then there is an addendum to the contract for $300 for an underinsured daily rate of $300? It is a discount that the facility provides to uninsured clients just as a Dr. would for an office visit if you don't have insurance?
Title: Re: Mental Health Billing
Post by: PMRNC on October 27, 2011, 11:26:18 AM
The proper way to show this is to putt full charge and SHOW the discount using a discount adjustment code. This way if ever patient submits it they have the full charge and you have done nothing wrong because the discount has been shown/disclosed.
Title: Re: Mental Health Billing
Post by: Angie on October 27, 2011, 12:11:11 PM
So if we bill the insurance for the full rate of 400.00 a day for 10 days they have authorized  (we are not contracted so they are going to pay what they are going to pay) and then after the 10th day they are not going to pay anymore, we can bill the parents the uninsured rate (discount) of $300 and just show the $100 adjustment, correct?
Thank you for all your helpful information! It is like Christmas morning when I go to click on show new replies to your posts and there is information there ;D
Title: Re: Mental Health Billing
Post by: PMRNC on October 27, 2011, 01:08:30 PM
This is a rather grey area because technically you MUST show the discount and give same discount to the carrier as you would the patient. With THAT said:
Show all your discounts to the carriers and to the patient. For example if you are billing the carrier 20 days @ $400 per day = $8000.00 now the carrier is only going to pay the allowable for the 10 days so there will be $4000 left.  Showing the discount might technically lower the reimbursement but legally that's how it is supposed to go.

A patient's out of pocket expenses are a part of the "cost sharing" provision of their contract with the insurer, by manipulating that fee with a discount you are giving to patient but NOT the carrier, that is legally a breach of contract.  So this is how it COULD go..  let's say carrier pays 80% of the $4000 (10 days) and they pay $3200 (not sure you said this was participating carrier in which case the $800 would either be a par adjustment OR patient responsibility (I'm only using the 80% as example).     

Even though the carrier only pays for 10 days, the left over days/amount is still considered patient out of pocket.  I know this really doesn't answer your question..but my advice would be to get the balance (after discount amount) from the patient up-front and show it as paid on the claim. Also refer to the office policy for discounts, if you only offer discounts to cash patients, then I would say you shouldn't discount this UNLESS patient pays the out of pocket first.
Title: Re: Mental Health Billing
Post by: Angie on November 01, 2011, 12:23:03 PM
Linda so even though we are not contracted with any of the insurance companies (we are located in UT) we cannot bill our daily rate of $400 a day to the insurance while the insurance has authorized those days and then after they deny and are not going to fund any longer we cannot give the parents a discout at the $300 a day per the addendum to the patients contract for no insurance as we give a reduced rate for cash patients?
Say the insurance authorized 10 days. The parents don't pay for those 10 days we just bill the insurance 10 days at $400 a day then on the 11th day when the insurance has denied services we would reduce the rate to $300 a day for cash patients and the account goes private pay.
Sorry if this does not make sense...I'm trying...... :-\
Any advice????
Title: Re: Mental Health Billing
Post by: midwifebiller on November 01, 2011, 01:41:27 PM
Most of our 50+ providers are out-of-network (OON).  There are a couple of gray areas with OON providers, so we consulted an insurance attorney, who in turn consulted with his peer group on this matter.

If you know the insurance company will not reimburse a service, there is no need to send a claim.  After the authorized claims have been sent, you can then change the account to private pay and offer a discount.
Title: Re: Mental Health Billing
Post by: Angie on November 01, 2011, 02:11:04 PM
Thank you for the information!
Do we have to collect what the insurance does not pay from the patient since we are out of network and do not have a contract?
Say we bill $4000 and they only allow $3000; can we write off the difference as an Adm adj or do we have to collect that from the patient?
Title: Re: Mental Health Billing
Post by: PMRNC on November 01, 2011, 06:35:50 PM
Kelli, I agree.. I was told same thing..  THEIR problem is that they KNOW the insurance will only pay portion..they want to write-off the rest or partially write off (discount) but if they do it "routinely" I'm still seeing this as a problem  ::)
Title: Re: Mental Health Billing
Post by: Angie on November 01, 2011, 07:55:25 PM
Linda can you explain the "problem" please?
We do know the insurance will only pay their allowed amount; which we don't know what that is because we are OON; my question was if had to collect the difference of the billed amount and allowed amount from the patient or if we could write that off and the member only pays what was applied toward their deductible, copay, coinsurance per the EOB.
Does that make sense? We are just trying to help this particular family that is in a very unique situation.....
Title: Re: Mental Health Billing
Post by: PMRNC on November 02, 2011, 10:41:42 AM
I did explain in a previous post. In an OON scenario, the insured STILL has a contractual obligation of "cost sharing" which means they MUST pay ANY out of pocket expenses.. PERIOD. When that plan pays THEIR portion of the contracted agreement ($400 in your case) the patient is contractually and legally obligated to pay THEIR portion. WAIVING any of that out of pocket routinely (routinely doesn't mean every time for that patient, it means routinely for all types of cases like this). Legally the patient is responsible for THEIR portion of out of pocket and yes, that includes non covered fees. The same would be said let's say for example the patient only has 30 visits a year for chiropractic but they go 40 times, their cost sharing and legal contractual obligation is the other 10 visits according to their plan's policy (contract).   See what I'm saying.  Now you can waive or discount with a proper financial hardship agreement completed but not done routinely, rather done by the office's policy and documented in the patient's file.   
Title: Re: Mental Health Billing
Post by: Angie on November 02, 2011, 11:23:08 AM
Thank you for the clarification Linda, sorry for the misunderstanding. Your information is very helpful.