Payments > Patient Billing

Billing patients when insurance benefits have been exhausted



I bill for a speech therapist and the charge is $120 for a speech session.  The question is if she is out of network with an insurance company and the insurance applies the the entire amount to the patients deductible can we charge the patient a lesser rate until the deductible is satisfied?  Also what about when insurance benefits are exhausted?  Can we lower the rate that we would have ordinarilly charged insurance?


If the provider is out of network( no contract at all), I would bill the patient for the whole $120. The patient will need then to file his own claim to the insurance co.

I understand we can do that because we are out of network (no contract at all) but my question really was can we leagally charge our cash rate which is less than what we charged insurance while the deductible is being satisfied - and the same question when benefits have been exhausted.  Hope I explained it correctly this time.

Thanks for your help

Actually you are not suppose to charge the insurance company one rate, then charge the patient another.  This is a very common question.  We have looked into it at great depth.  Being non par makes it a little different, since they cannot remove you from their panel, but if you are a participating provider and you charge the patient less, the insurance will remove you from their panel if they find out.  In any case, it is highly frowned upon by insurance carriers.  I am not sure of the legality end.  I wouldn't recommend it unless you can find a creative way to show a reason for billing the lower amount to the patient.

As far as when the benefits are exhausted, it is kind of the same rule.  However, this one is a little easier to get around.  If the patient is a cash patient or if their insurance will not cover the services, you can have a cash rate that is on a sliding scale, and make the lowest fee at such a level that all patients fall into it.

Hope that helps

Actually, The Law allows you to give a patient a discount for upfront payment, however this would need to be a universal amount.  It also allows you to Negotiate with the patient for the balance of the bill after 3 statements. Basically this is so Doctors can get what they can from a patient without sending them to collections. It is better for us to take a 30-40% discount from the patient then to send them to collections.


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