Author Topic: Collecting ded/copay/coin. for OON patients-Legal???  (Read 1919 times)

PTBILLER

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Collecting ded/copay/coin. for OON patients-Legal???
« on: June 14, 2010, 08:34:00 AM »
Good Morning All-

I have a small billing service with clients all over the US.  I'm hoping the answer to this question can be relayed to all my clients, no matter where they are.  This question is referring to a provider that is giving or wanting to give patients a "discount" or collect " in network" (even though they are not and obviously don't have a contract with the insurance provider). 

Example:  United Healthcare patient comes in and has services which are billed out at $200.  Since the provider is OON, the provider wants to charge the patient the 10% IN NETWORK fee for services and write off the extra 20% (OON coinsurance is at 30%). 

Is it legal to do this??  What about if the patient has a HIGH OON deductible and the provider wants to collect IN NETWORK deductible.  After the IN NETWORK deductible is met, the patient just pays coinsurance even though that amount is still going towards their OON deductible.  UGH....sounds so confusing.  Hope someone can enlighten us!!!
Thanks Guys!!
Pam McKewen

PMRNC

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Re: Collecting ded/copay/coin. for OON patients-Legal???
« Reply #1 on: June 15, 2010, 10:38:06 AM »
No it's not legal. It's a simple concept if you look at it this way. All patients should be charged the same fee as the insurance is charged. The patient is also in violation of their policy regarding cost sharing they are not meeting their true and legal responsibility of "cost sharing" within that policy.
This is why I tell my providers ONE fee schedule across the board... cash, insurance (any insurance) and then you kill two birds with one stone. You keep your butt covered AND you are reporting true costs which is part of the big problem in healthcare today.. doctors are billing out based on multiple fee schedules and therefore the insurance carriers are not getting accurate numbers in order to base their fee schedules.. in essence the doctor is hurting their own profession by billing multiple fee schedules.. Yes it's legal, but it is playing with fire and not the correct way to do things.  What your provider is doing is justifying the fraud by changing the billing schedule.. I can tell you now from having had worked for insurance companies they do record fee schedules (billing fees) with procedure codes and if there is a discrepancy they will flag the providers and eventually it's going to catch up with them.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

PTBILLER

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Re: Collecting ded/copay/coin. for OON patients-Legal???
« Reply #2 on: June 15, 2010, 04:57:12 PM »
Hi Linda-

They use the same fee schedule for all charges.  No matter which insurance payor it is being submitted to.

The question that I need is pertaining to what they can discount their patients at.  If they don't have a contract with an insurance carrier, they are going to be reimbursed OON.  Can the provider collect an "in network" coinsurance/copay and w.o. the balance as "professional courtesy", "prompt pay", etc? 

Also, what about OON "high" deductibles being "overlooked" and just charging for in network deductibles.  Basically, the patient is going to the OON provider, but being seen as if in network.  What part is/is not legal?? 

Thanks!
Pam McKewen

PMRNC

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Re: Collecting ded/copay/coin. for OON patients-Legal???
« Reply #3 on: June 16, 2010, 11:41:47 AM »
Unless the provider is offering the same discount to the insurance company (par/non par has nothing to do with it) OR the provider has a hardship agreement with that patient it is illegal for "providers to routinely waive out of pocket expenses"   Of course out of network is going to be lower reimbursement and the advantage is that the provider can collect the rest from the patient. If the provider wishes NOT to have the patient such large out of pocket expenses and he wants to collect more from the carrier.. go par.  :o

The law says it is illegal for providers to routinely discount....etc etc. It's pretty straight forward. He can have a hardship agreement with the patient but it must be fully documented in the patient's file. It cannot be done routinely with all patients. It is illegal.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com