Medical Billing Forum

General Category => General Questions => Topic started by: best biller on April 25, 2013, 01:03:06 PM

Title: out of network provider
Post by: best biller on April 25, 2013, 01:03:06 PM
Hi everybody,
 Is there a way for an out of network provider to receive payment from united health care to her office, or only the patient can receive payment?
Title: Re: out of network provider
Post by: RichardP on April 25, 2013, 04:03:29 PM
We have a client who is a non-participating provider for all insurance.  Cash only.  Patients signs a statement that assigns benefits to the provider.  That is noted on the CMS 1500 we send to the insurance company (patient has assigned benefits to provider).  Insurance company calculates what they will pay against what we billed and sends that payment to the provider.  Provider has patients with United Healthcare where payment is sent to provider, even though provider is non-participating (this is California).

  1.  If patient paid cash at time of service, and if patient is due a refund after insurance pays, provider's office issues refund to patient (when we tell them what it is).
  2.  If patient did not pay cash at time of service, we balance bill for the remainder.

The exception is Medicare.  Patient cannot assign benefits to the provider, so payment is sent directly to patient.

There are some few other insurances in California that will not send payment directly to the provider, even if the patient authorizes it.  You will have to figure out which carriers those are for your own state, since insurance rules and practices vary from state to state.
Title: Re: out of network provider
Post by: best biller on April 25, 2013, 04:24:05 PM
Thanks for the answer
Title: Re: out of network provider
Post by: PMRNC on April 25, 2013, 05:53:33 PM
Quote
We have a client who is a non-participating provider for all insurance.  Cash only.  Patients signs a statement that assigns benefits to the provider.  That is noted on the CMS 1500 we send to the insurance company (patient has assigned benefits to provider).  Insurance company calculates what they will pay against what we billed and sends that payment to the provider.  Provider has patients with United Healthcare where payment is sent to provider, even though provider is non-participating (this is California).

If patient pays cash and provider is non par why do you have patient sign an AOB?  I know BCBS won't issue check to NON BCBS par providers as they don't honor assignment for non par.  Not sure why UHC wouldn't send benefit to the patient so long as there is no AOB.
Title: Re: out of network provider
Post by: RichardP on April 26, 2013, 11:03:23 AM
If ... provider is non par why do you have patient sign an AOB?

We (billers) don't have the patient sign the AOB.  The doctor does.  There is a certain logic to why he does it, given that there is an in-house lab involved and he doesn't charge the patients cash for the labs.  Mostly, doc just wants to make certain he gets paid for everything he does.  If there is any money left over, he refunds it to the patient.

I was just giving best biller real-world evidence that United HealthCare in California will send payment to the doctor.  Either Blue Shield of California or BCBS will not send payment to doctor for us in California as well.
Title: Re: out of network provider
Post by: PMRNC on April 26, 2013, 04:24:48 PM
Quote
We (billers) don't have the patient sign the AOB.  The doctor does.  There is a certain logic to why he does it, given that there is an in-house lab involved and he doesn't charge the patients cash for the labs.  Mostly, doc just wants to make certain he gets paid for everything he does.  If there is any money left over, he refunds it to the patient.

You know I meant your providers/clients ;)   I imagine with labs unless patient pays up front there would be an AOB, but for my clients they know if a patient pays cash NOT to do assignment of benefits. I used to work for a few carriers and the patients that would call and complain about that was a big thing, technically a carrier can flag a provider for it if they are receiving payment and sending in an assignment of benefits. I've seen carriers that don't ACCEPT assignment for non par but never seen one that wouldn't send payment to patient. Policies are between patient and carrier.
Title: Re: out of network provider
Post by: RichardP on April 26, 2013, 06:34:34 PM
You know I meant your providers/clients ;)

Actually, I wasn't sure, and I didn't want to presume.  What with all the talk about billers growing into practice management, and sometimes becoming practice managers and running the doctor's office ...

As a non-par guy, including Medicare, his fees are quite a bit higher than what the insurance pays.  When the insurance payment goes to the patients, they too often find other things to do with the money than pay the doctor.  This setup ensures that the doctor gets his money first, so he can stay in business and provide top-notch care to his patients (not all patients can pay 100% of what they owe for each visit, and the doctor tries to accomodate his patients).  New patients are notified of this setup before the doctor does any procedures, so they are free to go to another provider if they don't like it.  Some go, but most don't.  Given that doctor is out of network, the patients would have to bill the insurance themselves to get reimbursed.  We bill for them as a courtesy, and most appreciate that.  We have a number of non-par clients who do this.   They've been clients for ten years and we haven't had any problems yet.

On a slightly different note, but sort of related: here's a slice of life.  Most of our clients are located in Beverly Hills and are a mixture of old and young and in-the-middle, age-wise.  They serve a healthy segment of the entertainment industry, both old and young.  Consider our clients who have been cash-only to this market for the past 40 years.  They charged whatever they wanted, and got paid for it.  Then the patients, who have never ever balked at paying outrageous rates for top-notch medical care (Edit: they have accountants pay for it all  8); life's been good to them so far), turn 65.  Time for Medicare.  So the patients sign up, in spite of their wealth.  Suddenly, a cash patient is now a Medicare patient and we must bill Medicare (participating provider or not).  Suddenly, charges that used to bring in thousands now only bring in hundreds.  Doctor's income takes a major hit, but so does ours (since we charge a percentage).  Over the past five years or so that has affected a couple of our clients - and by extension, us - big time.  Didn't see it coming until it occured.  It makes sense when you think about it - the patient letting Medicare pay for stuff that the patient used to pay for.  It was just not something we thought through until it began to happen.

(Brownie points for those who get the reference.)
Title: Re: out of network provider
Post by: PMRNC on April 26, 2013, 06:46:49 PM
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As a non-par guy, including Medicare, his fees are quite a bit higher than what the insurance pays.  When the insurance payment goes to the patients, they too often find other things to do with the money than pay the doctor

I get that..but that's what AOB is for.. You cannot blanketly  file an AOB with any carrier (par or non par) if none exists.
Title: Re: out of network provider
Post by: RichardP on April 26, 2013, 06:55:59 PM
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You cannot blanketly  file an AOB with any carrier (par or non par) if none exists.

I seriously don't get what you just said.  The patient signs the assignment of benefits statement.  They have insurance.  They are signing those insurance benefits over to the doctor.  So what do you mean by "if none exists".  That is what is confusing me.

I edited my last post slightly while you were posting.
Title: Re: out of network provider
Post by: best biller on April 28, 2013, 11:25:31 AM
Thanks so much for the info.
Title: Re: out of network provider
Post by: PMRNC on April 28, 2013, 04:34:15 PM
Quote
I seriously don't get what you just said.  The patient signs the assignment of benefits statement.  They have insurance.  They are signing those insurance benefits over to the doctor.  So what do you mean by "if none exists".  That is what is confusing me.

Well, I'm not sure why a patient would sign an AOB if paying cash/upfront. If there is full payment in the payment field of the CMS1500 but yet there is an assignment of benefits, one had better exist but again, I'm not sure WHY a patient would assign benefits if they have paid for services.

Title: Re: out of network provider
Post by: best biller on April 30, 2013, 09:21:05 AM
My clients patients do not pay up front. Now there is one pt. which stopped coming and when we call to collect payment she does not answer the phone. We want to try avoiding this in the future.
Title: Re: out of network provider
Post by: PMRNC on April 30, 2013, 11:14:53 AM
Like I mentioned I was never aware UHC did not honor assignment for non par providers.. But if they are not but yet you have an assignment of benefits, I would FIRST clarify this with the carrier that they are NOT honoring assignment. I only know that BCBS does this for non par as it's built into their policies. If you establish they are paying the patient properly (even with an assignment) then it might be time to revamp your office financial policy so you can collect full fees at the time of payment for these patients.
Title: Re: out of network provider
Post by: Medicare56 on April 30, 2013, 02:36:38 PM
We have a client who is a non-participating provider for all insurance.  Cash only.  Patients signs a statement that assigns benefits to the provider.  That is noted on the CMS 1500 we send to the insurance company (patient has assigned benefits to provider).  Insurance company calculates what they will pay against what we billed and sends that payment to the provider.  Provider has patients with United Healthcare where payment is sent to provider, even though provider is non-participating (this is California).

  1.  If patient paid cash at time of service, and if patient is due a refund after insurance pays, provider's office issues refund to patient (when we tell them what it is).
  2.  If patient did not pay cash at time of service, we balance bill for the remainder.

The exception is Medicare.  Patient cannot assign benefits to the provider, so payment is sent directly to patient.

There are some few other insurances in California that will not send payment directly to the provider, even if the patient authorizes it.  You will have to figure out which carriers those are for your own state, since insurance rules and practices vary from state to state.

if patient get's the money, how will the provider then compensate for their supply?
Title: Re: out of network provider
Post by: PMRNC on April 30, 2013, 02:45:18 PM
Quote
if patient get's the money, how will the provider then compensate for their supply?

Well again, if the carrier did not honor a valid assignment of benefits when they should have the carrier has the responsibility for reprocessing the claim, properly assigning benefits to the claim with payment to provider and then they would seek reimbursement back from their insured/patient.  BUT if the carrier processed properly and doesn't honor assignment of benefits OR there was no assignment then the provider is left to bill the patient.   THIS AGAIN IS NON PAR
Title: Re: out of network provider
Post by: Medicare56 on April 30, 2013, 04:17:07 PM
so basically, we have to then ask the patient to pay us the money? It is assumed that if the assignment is not accepted then the carrier won't pay for the supply anyway right?
Title: Re: out of network provider
Post by: PMRNC on April 30, 2013, 04:43:02 PM
Quote
so basically, we have to then ask the patient to pay us the money? It is assumed that if the assignment is not accepted then the carrier won't pay for the supply anyway right?

Your scenario might be different.   We were talking about Assignment of Benefits and NON par providers where the carrier reimburses the patient.  No, you can't assume because an assignment of benefits was not honored that the service wasn't covered. These are completely different things.
Title: Re: out of network provider
Post by: best biller on May 02, 2013, 06:13:20 PM
can anyone help me and let me know where i can get the aob?
Title: Re: out of network provider
Post by: PMRNC on May 02, 2013, 06:16:45 PM
The AOB is Assignment of Benefits and should be a part of your office financial policy the patient signs, it should be a separate section for them to sign to assign benefits. If the office had one it should be in the patient's file, if not you will need the patient to sign one next time they come in. You can try and send them one to file but it won't help for claims already filed w/out an AOB.
Title: Re: out of network provider
Post by: RichardP on May 06, 2013, 02:13:37 PM
If there is full payment in the payment field of the CMS1500 but yet there is an assignment of benefits, one had better exist but again, I'm not sure WHY a patient would assign benefits if they have paid for services.

1.  My initial response was to the specific question - would United Healthcare send payment to the provider when he was not a participating provider?  My response was direct: we have a provider who is non-participating with United Healthcare, his patients have signed an Assignment of Benefits, and United Healtcare does send the payment directly to the provider.  When I said that, I was only confirming that United Healthcare in California does send payment to a non-participating provider.  I was not laying out the details of how that worked.

2.  Linda's questions ask to clarify an issue separate from the original question I was answering.  She was correct to bring this up for purposes of clarification - I just didn't understand what she was asking initially.  So -

a.  We do have an Assignment of Benefits on file for each patient where we print "Signature on File" in Box 13 of the CMS 1500.  We never intentionally send a CMS 1500 with "Signature on File" in Box 13 of the CMS 1500 when we actually have no such signature.  If there is full payment, or partial payment, for services, we account for that.  See Point 2(c) below.

b.  Why would the patients sign an Assignment of Benefits with a non-participating provider?  I don't know.  But they do.  Up until recently, the patients filed their own insurance.  We have only recently begun billing as a courtesy to the patients.  The provider may ultimately discover that the assignment of benefits to the non-participating provider, and the providing of refunds to patients when due, might be more hassel than it is worth and drop it.

c.   "Cash Only" is the objective.  Partial payment is the reality in most cases.  If we are informed that payment has been made before the CMS 1500 is completed and submitted to the Insurance Carrier, the amount of payment shows up in Box 29 of the CMS 1500.  If we are not told that payment has been made, we can't know.  We are operating in real time, not in theory.  If payment of 100% is made, and we are told in time, Box 13 is blanked out, Box 30 = 0 due to the provider, and the Insurance Carrier sends any payment due directly to the patient.

Keep in mind that, as a non-participating provider, the doctor's charges are considerably higher than what the insurance company will pay.  So, if patient pays less than 100% of what is owed, and we are not notified of this, so that we bill the carrier for 100% of the charges, the patient often will still owe money to the doctor after the insurance pays.  Each patient's situation is different.  And billing for each patient involves some combination of office visit, in-house labs (high complexity), x-ray, ultra-sound, and bone density scanning.  It is not simple medicine; therefore it is not simple, cookie-cutter billing.