Author Topic: Discounting a Non-Covered Service to a pt that has insurance  (Read 4000 times)

krudolph

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We are a specialty practice and are Anthem Providers.  Many of our patients that have Anthem do not have coverage for office visits.  We submit the claims to the insurance company and get back EOB's indicating the allowed fee (our contracted rate with Anthem) as what to charge the patient.  If you print the patients benefits it reads "Professional Ofiice Visit In Network - Co-Insurance 100%-does not contribute to out of pocket"  Because it does not contribute to their copay/deduct/out-of-pocket can we discount this fee even further based upon our sliding scale policy and be legally correct?

PMRNC

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Re: Discounting a Non-Covered Service to a pt that has insurance
« Reply #1 on: June 05, 2009, 01:12:12 PM »
I have no idea what that means? They have NO coverage? Is this for all patients? Was there something specific denied?
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krudolph

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Re: Discounting a Non-Covered Service to a pt that has insurance
« Reply #2 on: June 05, 2009, 01:21:25 PM »
Sorry, let me clarify.  The patients do have coverage thru Anthem and we are a participating provider; however, their policy does not cover office visits and the patient is responsible for 100% but because we are contracted with Anthem we have agreed to accept the allowed fee and not charge the patient our full fee.  My question is because it is not a covered benefit and the pt portion does not go towards deduct or the patient's out of pocket expenses can we give the patient a prompt pay discount if we do this for all Anthem patients that have the same situation?  Basically the only benefit the patient has with Anthem on Office Visits if going to an in-network provider is it will be adjusted down to the Anthem allowed amount.

Pay_My_Claims

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Re: Discounting a Non-Covered Service to a pt that has insurance
« Reply #3 on: June 05, 2009, 02:56:15 PM »
i'm confused too. I would think that even if par, if it's a non-covered benefit, the allowed would be 0, and it would all drop to patient responsibility. I would contact Anthem for clarity as to why they have an allowed for a non allowed charge.

PMRNC

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Re: Discounting a Non-Covered Service to a pt that has insurance
« Reply #4 on: June 05, 2009, 04:02:30 PM »
Yes.. What charlene said!.. but I'm still stuck as to why they don't have coverage for office visits? Is their coverage just for hospitalization ?  ???
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Michele

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Re: Discounting a Non-Covered Service to a pt that has insurance
« Reply #5 on: June 05, 2009, 09:02:57 PM »
I've actually seen a few plans like this.  We have called and been advised that office visits aren't covered under their plan.  I'm like "If you don't cover office visits then what do you cover?"  They usually cover hospitalization, surgeries, and other things, but not office visits. 

So they are processing the claim, showing the Anthem allowed amount, but not making any payment since it is not a covered benefit under the plan.  But the provider is required, since they are a participating provider to accept the allowed amount, even though it is not being applied to a deductible or out of pocket.  My opinion is that if you are billing patient for the allowed amount, but offering a prompt pay discount, that is ok.

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Pay_My_Claims

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Re: Discounting a Non-Covered Service to a pt that has insurance
« Reply #6 on: June 06, 2009, 12:45:54 PM »
OK, I think I can get it. Anthem DOES pay for office visit, however the Anthem plan they have is basically a hospital policy. Since they do have an allowed amount for office visits, they have to accept that allowable because they are a par provider, even though they have no coverage.

PMRNC

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Re: Discounting a Non-Covered Service to a pt that has insurance
« Reply #7 on: June 06, 2009, 02:19:44 PM »
No No no.. If this is indeed a hospitalization ONLY Plan (catastrophic coverage) they are not going to "allow" anything, this does not mean the doctor eats the charge. The plan is not a true major med plan, therefore it should be treated as "no coverage", regardless of par status. There should be NO allowable since they wouldn't have a fee schedule for office visits on a hospitalization plan. The doctor is able in that situation to collect the full fee. When and if benefits were verified this would have pre-established this for the patient.
If the patient protests, you merely would refer them to their policy booklet which would explain what their policy covers.
It wouldn't be reasonable to expect to go to the doctors and have your insurance pay for the visit when your insurance only covers surgical and hospital procedures.
Now again, this is for hospitalization and/or catastrophic plans.. we don't know for sure if that's the case here.
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Michele

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Re: Discounting a Non-Covered Service to a pt that has insurance
« Reply #8 on: June 06, 2009, 07:20:02 PM »
Actually, there question was if it was ok to offer a prompt pay discount, an amount lower than the allowed amount.  Based on all that you said, I think I was ok with my previous response stating they can indeed offer a discount, right?

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PMRNC

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Re: Discounting a Non-Covered Service to a pt that has insurance
« Reply #9 on: June 06, 2009, 07:50:16 PM »
Yes, I would think it would be ok. I'm sorry I should have gone back to read the original question!  ???
I would think if they have other patients with same coverage though they might want to cover themselves with a financial hardship agreement? Or I could be overthinking today.
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Pay_My_Claims

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Re: Discounting a Non-Covered Service to a pt that has insurance
« Reply #10 on: June 06, 2009, 11:13:57 PM »
Well the question would be is the discount higher or lower than the allowable that Anthem is allowing. According to what he posted. The Anthem coverage they have doesn't cover office visits, but Anthem does have an allowable for one. IE: they bill 45.00 client has no coverage 100% responsible, but Anthem's allowable is only 30.00. They want to bill the client more or less than Anthem's allowable is that ok? Anthem states they can bill 30.00 since they are par providers they can't charge more than the allowable. If they prompt pay 25.00 ok, they are adjusting off 5. if they prompt pay 35.00 no, they are charging the client more than the contracted allowable rate per Anthem.

Michele

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Re: Discounting a Non-Covered Service to a pt that has insurance
« Reply #11 on: June 07, 2009, 06:04:43 AM »
The question states "discount the fee even further" so they mean lower than the anthem allowable. 

I've actually seen eobs with this scenario.  They process the charge, show the billed amount show the allowed amount, show copay $0, ded $0, pd $0, pt responsibility $(allowed amount). 

I thought as long as they billed the allowed amount, but then offered a prompt pay discount they would be ok. 

Boy, this one certainly prompted some healthy discussion!   :)

Michele
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PMRNC

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Re: Discounting a Non-Covered Service to a pt that has insurance
« Reply #12 on: June 07, 2009, 09:19:06 AM »
I couldn't see in his/her post where there was an allowable amount given to us.. if the PLAN is just catastrophic or hospitalization there won't be a fee schedule for Major Medical charges, you can't have an allowable fee when there is no coverage, again we don't know for sure. 
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Pay_My_Claims

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Re: Discounting a Non-Covered Service to a pt that has insurance
« Reply #13 on: June 07, 2009, 06:20:15 PM »
There wasn't an allowed amount given, it was just used as an example.

Scenario: I have BCBS of NC PPO. My plan does not cover for a gyn exam. My girlfriend also has a BCBS of NC PPO policy,but hers does. The gyn exam is an exclusion on my plan, but does not mean BCBS of NC does not cover gyn exams, just means on my plan it will not cover. When I see my pcp and have a gyn exam I have to pay out of pocket since it is non-covered. If BCBS of NC didn't cover at all any gyn exams, then I would be 100% liable, and the entire fee would drop to me. Since BCBS does have an allowable, it is just non-covered by my plan, BCBS sends the claim back with an "allowed" amount, and that is the max they can charge me. This is what I feel the poster is speaking of. If he knows the office visit isn't covered, he can tell them they don't have that benefit, and will be responsible per Anthem guidelines for XX.xx, but if they pay today they can pay XX.xx (lower than the allowed amount). If he is prompt paying them more than the allowed by saying we charge XXX.xx and its non covered by your insurance, but if you pay XXX.xx  (more than Anthem allows) then he is over charging the patient and can not since he is a par-provider. Just because their plan doesn't cover the visit doesn't mean he can bill more than the allowed.

Pay_My_Claims

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Re: Discounting a Non-Covered Service to a pt that has insurance
« Reply #14 on: June 07, 2009, 06:24:32 PM »
The question states "discount the fee even further" so they mean lower than the anthem allowable. 

Michele

he could also mean discount their fee lower which is more likely what most providers will want to do. They usually don't want to drop it lower than what the insurance company allows.