Author Topic: Needing Clarification PLEASE!  (Read 2186 times)

peaflog4929

  • Newbie
  • *
  • Posts: 4
Needing Clarification PLEASE!
« on: March 29, 2011, 01:32:05 PM »
I need clarification...
All patients pay the same discounted out of pocket service, however, the patients with insurance, their insurance company is being charged more then what the patient is charged. If the insurance company doesn't pay we do not go back to the patient with an additional bill.
Ex. Patient Charge $3000(includes services above and beyond that price) this is their discount. Both non-insurance and insurance patients are being charged the same discounted amount.
     Insurance charged $6000(the amount that it would actually cost the patient for the services) insurance pays $3800...the $3000 would go back to the patient, and the provider would keep the rest of the remaining $800.

Just wondering if this is legal?
« Last Edit: March 29, 2011, 02:19:57 PM by peaflog4929 »

rdmoore2003

  • Hero Member
  • *****
  • Posts: 625
  • Live Life and Love God
Re: Needing Clarification PLEASE!
« Reply #1 on: March 29, 2011, 03:54:56 PM »
if I am understanding it right,  no its not legal.
for each cpt code- you should set an amount.  file to insurance then charge patient per eob.
if the patient is getting a discounted rate, you need paperwork to back up why they get a discounted rate.  ex:  pt. does not have insurance and works part time. that information needs to be documented and signed acknowledging understanding by the staff and patient on why patient is getting discounted rate.
Regina

peaflog4929

  • Newbie
  • *
  • Posts: 4
Re: Needing Clarification PLEASE!
« Reply #2 on: March 30, 2011, 05:59:51 AM »
We are out of network for our services, so we always (whether the patient has insurance or not) recieve payment before the insurance company is billed.
All the cpt code prices never change. The discount is given to each patient insured or not, and is documented.
So, those clients with insurance who where given the discount, there insurance is billed the whole amount, not the discounted rate. Our services for what we provide are almost double the discounted rate.
So again, if the discount is documented (which it is) and all patients are charged the same amount, insured or not, is it legal?
Also, we are never going back to the patient with insurance to collect if the full amount is not paid out by insurance. We eat our loss.
Any patients that have additional charges outside of our discounted package are all charged the same amount for that service...
ex. Patient needs to be tested for a UTI that goes to the lab. This would be outside the discounted package, and insured or not they will be charged. If the patient has insurance that charge will get filed, however all patients still need to pay out of pocket at the time of service because we are out of network.
Additional thoughts appreciated!

rdmoore2003

  • Hero Member
  • *****
  • Posts: 625
  • Live Life and Love God
Re: Needing Clarification PLEASE!
« Reply #3 on: March 30, 2011, 10:52:05 AM »
 yes as long as its documented, legal
Regina

peaflog4929

  • Newbie
  • *
  • Posts: 4
Re: Needing Clarification PLEASE!
« Reply #4 on: April 04, 2011, 08:28:00 AM »
So, I have officially gotten it is legal and not legal from the same replier.

Can you clarify why you changed your response from illegal to legal? It is my belief that it is legal, but I want to make sure.

rdmoore2003

  • Hero Member
  • *****
  • Posts: 625
  • Live Life and Love God
Re: Needing Clarification PLEASE!
« Reply #5 on: April 04, 2011, 11:33:32 AM »
as before:
1) each cpt code must be given a set amount
2) if you are not in network with a patients insurance, and you have documented why you are charging a lesser amount than the amount set for that code

 LEGAL

it helps alot that when you ask a question, to be very descriptive in what you are asking( in detail).   as my first response, you will see that I stated,  "if I am understanding the question".   if the question is confusing, answers will be confusing.

hope this helps
Regina

PMRNC

  • Hero Member
  • *****
  • Posts: 4252
    • One Stop Resources & Networking for Medical Billers
Re: Needing Clarification PLEASE!
« Reply #6 on: April 04, 2011, 03:17:02 PM »
DISCLAIMER:   For actual clarification "legally" you should consult with your (or practice's) attorney!

Quote
All patients pay the same discounted out of pocket service, however, the patients with insurance, their insurance company is being charged more then what the patient is charged

I underlined the part that sticks right out.

IN network or OUT of network, if you are NOT Showing the discount TO the insurance company that is illegal. Whether you are in network or not, has no impact on the "cost sharing contractual agreement the patient/insured has with their carrier"  If you bill $100 to the patient on a $200 charge (normal charge) you must bill the insurance the $200 and SHOW the discount. The patient is required to pay their "cost". It is not right the insurance company does not receive the SAME discount. So basically the patient is always responsible for THEIR portion of any billed procedure.  

Quote
Ex. Patient Charge $3000(includes services above and beyond that price) this is their discount. Both non-insurance and insurance patients are being charged the same discounted amount.
     Insurance charged $6000(the amount that it would actually cost the patient for the services) insurance pays $3800...the $3000 would go back to the patient, and the provider would keep the rest of the remaining $800.

Of course that's not legal .. Why shouldn't the insurance company have the same discount? The patient is also in violation of their contractual agreement with their insurance company.

Again, in these cases it makes NO difference if you are par or not. If you give a discount to the patient you must SHOW that discount and present it to the carrier with the same opportunity. The patient is obligated to pay their cost-sharing regardless of any "discounts".  

Also.. this is sort of contradictory:
Quote
So, those clients with insurance who where given the discount, there insurance is billed the whole amount, not the discounted rate. Our services for what we provide are almost double the discounted rate.

You say the insurance is billed full amount, not discounted rate and then you go on to say your services are double the discounted rate?

Bottom line is this.  ALWAYS bill your normal charge. Any discount should be shown on the claim. Do that and you will not have a legal issue.  (PAR OR NON PAR)
 
« Last Edit: April 04, 2011, 03:21:26 PM by PMRNC »
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

peaflog4929

  • Newbie
  • *
  • Posts: 4
Re: Needing Clarification PLEASE!
« Reply #7 on: April 05, 2011, 08:29:53 AM »
Thank you for the additional imput...when you say "show the discount on the claim" where would you put this information? or di you include an addition sheet with the claim to the insurance company?

rdmoore2003

  • Hero Member
  • *****
  • Posts: 625
  • Live Life and Love God
Re: Needing Clarification PLEASE!
« Reply #8 on: April 05, 2011, 09:23:07 AM »
Thank you Linda.   I have read this question over and over and each time I had a different understanding of it.   This is why I posted to have questions in detail.   I fully understand now that I have read your posts.   
Regina

PMRNC

  • Hero Member
  • *****
  • Posts: 4252
    • One Stop Resources & Networking for Medical Billers
Re: Needing Clarification PLEASE!
« Reply #9 on: April 05, 2011, 04:34:03 PM »
Quote
"show the discount on the claim" where would you put this information? or di you include an addition sheet with the claim to the insurance company?
You can do it two ways.  1. Reduce the service (billable) by the discounted amount (exactly)  Or you can show the discount in box 29.

Remember that plan's that contain a cost-sharing agreement (coinsurance, deductible = indemnity plans) WILL be reduced again ..because the patient IS responsible for those and there has to be an attempt made to collect.
For Par providers you can't do this at all because the par carrier will reduce and deduct the appropriate discount (PPO discount.. ) 

Example:  Doctor plans to discount $100.  Original Fee is $200.  Bill the insurance $100 and that is to be the "considered" amount by the carrier which means if the patient has an 80/20 plan, they are going to be responsible for the $20 coinsurance. It also means if the entire $100 is taken towards deductible the patient is still going to be responsible for the $100.00    The idea is that you need to be fair.. the carrier deserves the same discount on the "considered" fee.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com