Author Topic: Question about Patients Sending Claim to Insurance  (Read 3320 times)

lbd122

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Question about Patients Sending Claim to Insurance
« on: August 25, 2009, 04:13:55 PM »
Hello Everyone,

I have a patient who paid our cash rates.  She would like to send in a claim to her insurance now to see if anything will get covered (i.e. if they will get reimbursed for any of the bill).  So she would like me to send her the bill with the necessary information.  Here is my question:

Our billed charges differ from our cash rates.  So in the bill i create for her should her payments be reflected?  or Should I just leave it as the patient is being billed the entire billed charge amount? 

Sorry if this is hard to understand...here is an example (do I do A or B):

     Date       Description                        Charges          Insurance Pending       Payments/Adjustments        Patient Balance

A  8/25/09    Initial Evaluation (97001)      150.00                 0.00                              0.00                            150.00

B  8/25/09    Initial Evaluation (97001)      150.00                 0.00                              80.00                             70.00


Thank you!

PMRNC

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Re: Question about Patients Sending Claim to Insurance
« Reply #1 on: August 25, 2009, 04:41:01 PM »
That bill should be for whatever you charged her, it should not be different at all as that would be fraud.
If you billed her $150 and your normal rate is $200 and she paid $150 you don't want to give her a bill for $200 because she'll end up getting reimbursed more than she paid!  ???

The bill needs to match and if she has coinsurance or deductible that will get deducted as well.
Linda Walker
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Pay_My_Claims

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Re: Question about Patients Sending Claim to Insurance
« Reply #2 on: August 25, 2009, 08:43:52 PM »
Why would she pay cash if she has insurance. Why didn't you just bill a non-assigned claim??  Are you a contracted provider with the insurance???

PMRNC

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Re: Question about Patients Sending Claim to Insurance
« Reply #3 on: August 26, 2009, 08:30:48 AM »
There's nothing wrong with providers that take cash and have the patients file their own insurance AS LONG as they don't participate with that plan and as long as they are giving valid receipts/billings so that when this situation arises the patient has a bill for services rendered and paid to submit to their insurance company and they MATCH. You can't bill the patient one fee and the carrier another. 
Linda Walker
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Pay_My_Claims

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Re: Question about Patients Sending Claim to Insurance
« Reply #4 on: August 26, 2009, 09:19:17 AM »
Exactly, we do it often since we are non-par providers, but we generally file the claim for the client. I just want to know why she wants to file after paying her "discounted" cash rate???  Something smells to me.


PMRNC

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Re: Question about Patients Sending Claim to Insurance
« Reply #5 on: August 26, 2009, 11:27:26 AM »
We are just not used to seeing it, but she said the patient wants to now send the bill. The practice probably has an across the board rule not accept or file claims..again that's not common but we are starting to see it more frequently as doctors move away from insurance. It takes a special office to run this type of practice and they have to be in the right location and have maintained a steady stream of loyal patients. But really there's nothing wrong with it. Maybe this patient wasn't aware of their insurance and paid in full and later realized the services would be covered..
Maybe their benefits were reinstated.  But again, the bills have to MATCH.
Linda Walker
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Pay_My_Claims

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Re: Question about Patients Sending Claim to Insurance
« Reply #6 on: August 26, 2009, 01:17:58 PM »
OK, then question. Client pays for visit, as a cash discount. Provider is par with the insurance. Provider gives patient cash discount. He said 97001 150.00 (his fee schedule). Cash discount 80.00 and she pays 70.00. What if the allowed amount on that charge is 60.00??  and they are a network provider??

PMRNC

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Re: Question about Patients Sending Claim to Insurance
« Reply #7 on: August 26, 2009, 02:38:09 PM »

Quote
OK, then question. Client pays for visit, as a cash discount. Provider is par with the insurance. Provider gives patient cash discount. He said 97001 150.00 (his fee schedule). Cash discount 80.00 and she pays 70.00. What if the allowed amount on that charge is 60.00??  and they are a network provider??

you missed this post before my last one  :D


Quote
There's nothing wrong with providers that take cash and have the patients file their own insurance AS LONG as they don't participate with that plan and as long as they are giving valid receipts/billings so that when this situation arises the patient has a bill for services rendered and paid to submit to their insurance company and they MATCH. You can't bill the patient one fee and the carrier another.

Example of acceptable cash pay :

patient has Aetna PPO. Provider is NON par with Aetna. Provider normally charges $100 for 99213
He discounts the patient $20.00. Patient wants to file their own insurance (or office doesn't file for non par) Doctor gives bill to patient but the bill needs to be printed to either show full charge and break out the discount OR show the discounted fee.

DOS                        CPT                     DX                Charge          PMT       Adj             Balance

8/1/09                  99213                   250.00                $100.00         $80.00    $20.00            $0.00

OR


DOS                        CPT                     DX                Charge                PMT                   Balance

8/1/09                      99213                   250.00             $80.00                $80.00                    $0.00


Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

Pay_My_Claims

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Re: Question about Patients Sending Claim to Insurance
« Reply #8 on: August 26, 2009, 02:59:05 PM »
No, I understood your reply, I asked the poster why did the client not pay when they had insurance. I am not just going to ASSUME that they are non-par. Your replies to the post was as if they are non-par. I want to know if they are par, what are they going to do in regards to her filing her own claim!!

This is why I am asking the question because if they are par, and the payment she made isMORE than the allowable..... what??

PMRNC

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Re: Question about Patients Sending Claim to Insurance
« Reply #9 on: August 26, 2009, 06:37:21 PM »
I doubt this is non par, I took the question to mean the patient paid cash was maybe unsure of reimbursement and then decided to just give it a shot. Their question was just pertaining to the bill they need to give the patient which I think is common sense that it needs to match.. all the other stuff is just assumption...I've had patients say "oh we don't have insurance, then they pay cash and then later they want to submit to insurance, the carrier will still pay in most cases par or non and if there is no assignment they will reimburse the patient, occasionally in that situation the carrier will send the money to the provider. I just had a situation where my benefits were changed and I didn't get the new card or info for a visit I had to my family doctor on 8/1, I just paid him cash, when I got the card I gave it to the OM and she filed the claim for me and I got the check 2 days ago, I paid the office cash, I got a check and on the EOB they billed what they charged me so it all worked out. And they were par, we just didn't know the carrier at the time of the visit. Par providers SHOULD file the claims but there are certain circumstances they can't. If the carrier were to reject or deny the claim a simple call would have cleared it up.
Linda Walker
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One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

Pay_My_Claims

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Re: Question about Patients Sending Claim to Insurance
« Reply #10 on: August 26, 2009, 08:29:01 PM »
I totally understand and agree with the way the bill should be. Could be my overly peculiar self, but I just don't comprehend the "create the bill" question. Guess it would depend on how the offices are set up. Clients that filed insurance for reimbursements (we were non-par) would only need the superbill to file with the claim (proof of payment).They could download the insurance claim forms online The way you bill will always be the same. If you charge XXX for something, there is no separate fee for cash clients, only a discount. You should never "change" the charge, only do the adjustment. When we print out a statement for a client for taxes or claim filing, it has our charge, any payments or adjustments and balances due. 99.9% of every client I had always asked us to file for them because they don't know how. We have had several try to file and run into issues. (DME provider). We agree, I'm just nit-picking so pardon me :-)

Michele

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Re: Question about Patients Sending Claim to Insurance
« Reply #11 on: August 27, 2009, 07:22:24 AM »
The horse is dead already! 

Just kidding.  ;D

Michele
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lbd122

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Re: Question about Patients Sending Claim to Insurance
« Reply #12 on: August 27, 2009, 11:19:04 AM »
Hi Everyone,

oh wow...didn't know my question would get such heated responses!   ;D  Yes....we are an OON provider.  The patient paid cash b/c they did not think their insurance would cover the bill but they now want to submit the claim to see if they might be reimbursed for any of the fees. 

The rates are different b/c we have our regular "billed charges" (that are never reimbursed fully by insurance b/c of the allowable amts) and we have separate cash rates for those without insurance.  Usually our cash rates are higher than what insurance reimburses.  I asked the question b/c if we had submitted the claim to insurance we would have used our billed charges however since this patient paid the cash rates i was wondering which i needed to give her. 

So....what y'all seem to be saying is that there shouldn't be separate cash rates....just a discount?  Hmm...interesting b/c several other practices (including some big ones) had separate codes/rates for their cash patients.  But y'all would be the experts.  :D 

anyhow...thank you for all of your responses.  sorry it took me so long to reply....didn't know there were responses already. 

Pay_My_Claims

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Re: Question about Patients Sending Claim to Insurance
« Reply #13 on: August 27, 2009, 11:31:55 AM »
thanks for clearing that up regarding your provider status. My reason for inquiring was we are non-par providers (DME), and we offer discounts as well. If we charge the client more than the "allowed" amount, we can still balance bill so we would never owe the client any money. If you are par, you could potentially owe if you accepted more than your contracted rate. I dealt more with the abstract than your actual question of how to bill.

I can be anal that way  ;D

PMRNC

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Re: Question about Patients Sending Claim to Insurance
« Reply #14 on: August 27, 2009, 12:02:35 PM »
Quote
oh wow...didn't know my question would get such heated responses!   Grin  Yes....we are an OON provider.  The patient paid cash b/c they did not think their insurance would cover the bill but they now want to submit the claim to see if they might be reimbursed for any of the fees.

The rates are different b/c we have our regular "billed charges" (that are never reimbursed fully by insurance b/c of the allowable amts) and we have separate cash rates for those without insurance.  Usually our cash rates are higher than what insurance reimburses.  I asked the question b/c if we had submitted the claim to insurance we would have used our billed charges however since this patient paid the cash rates i was wondering which i needed to give her.

So....what y'all seem to be saying is that there shouldn't be separate cash rates....just a discount?  Hmm...interesting b/c several other practices (including some big ones) had separate codes/rates for their cash patients.  But y'all would be the experts.  Cheesy



It's not illegal to have different fee schedules but it is a VERY big disadvantage to do this. There are several reasons your provider wants to have ONE Fee schedule. The first reason is for ease of data retrieval. Let's say you want to look at your provider status with Aetna PPO, your provider needs to see the write-off/Adjustments for Aetna so that he can see how much money is being lost.. you can't do that if you are billing out Aetna PPO fee schedules. The other reason is it hurts the National Databases used to calculate U&C and fee schedules. Data to create these fee schedules and U&C is gathered by looking at charges nation wide and then sorting geographically. If your doctor is charging everyone by the fee schedule of their patients the data is going to be calculated in with all the others and it won't be accurate. It's a dis-service to all providers in your zip code area!

ONE fee schedule across the board is really the right way to do things. Your adjustments should be categorized accordingly.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com