Author Topic: 2 separate FEE schedules for ONE OFFICE  (Read 5052 times)

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2 separate FEE schedules for ONE OFFICE
« on: January 12, 2012, 06:07:10 PM »
I am dealing with a drug rehab center and they normally charge a flat fee for their entire service.  The fee they charge is way under the standard rate. 

I need to know if it is legal for them to charge one rate for their CASH PAYING PATIENTS and another rate for their patients that have & use their INSURANCE.

I have always thought that doctors offices did this and was wondering if it's legal for a drug facility to do this as well.  I want to stay ethical & legal.

ANy input is greatly appreciated!!!! 

Michele

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Re: 2 separate FEE schedules for ONE OFFICE
« Reply #1 on: January 14, 2012, 05:58:11 AM »
It is illegal to charge one fee for a cash patient and different fees to patients with insurance for the same service.  For example, if a patient comes in for a wart removal and they don't have insurance (cash patient) and the dr charges them $50 and then another patient comes in for the exact same thing but has good insurance and the dr charges for an 17111 for $95.  (Of course it would have to be the exact same number/size warts etc)  That is wrong.  The dr is charging higher based solely on the fact that the patient has insurance. 

So in the case of drug rehab, it is ok if they charge a flat fee for their entire service to cash patients and then break the charges out for billing purposes, IF they are charging the same fees.
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Angie

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Re: 2 separate FEE schedules for ONE OFFICE
« Reply #2 on: January 16, 2012, 01:34:33 PM »
So you cannot have a hardship agreement? I thought I  had read on one of the postings that it needs to be well documented in your policies and that it needs to be consistant. Say the flat daily rate is $400 a day but based on financial hardship the company agrees to administratively write off $100 per day because they have no insurance coverage and charge them $300 a day, is that illegal?

What about if they do have some insurance coverage (non par provider) and they bill the insurance $400 a day and then once the insurance stops funding they review their financial situation and do an administrative adj to the $300 a day, is that illegal???


PMRNC

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Re: 2 separate FEE schedules for ONE OFFICE
« Reply #3 on: January 16, 2012, 04:17:29 PM »
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So you cannot have a hardship agreement? I thought I  had read on one of the postings that it needs to be well documented in your policies and that it needs to be consistant.

What does YOUR policies and procedures say? how does your office financial policy define hardship?  That's where you get your answers, if you don't have one, well then it's good idea to get that done ASAP. You can have hardship agreements completed by patient's who QUALIFY as per your office financial policy.


Say the flat daily rate is $400 a day but based on financial hardship the company agrees to administratively write off $100 per day because they have no insurance coverage and charge them $300 a day, is that illegal?

That is a cash pay discount, nothing goes to any insurance company. As long as the patient's bill reflects this COURTESY discount your fine. IF they submit to an insurance carrier (even unbeknown to you) the bill MUST show the courtesy cash pay discount.  I think it's only best a practice do this when the patient has paid up front, otherwise they lose their incentive.

 
Linda Walker
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Angie

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Re: 2 separate FEE schedules for ONE OFFICE
« Reply #4 on: January 16, 2012, 04:30:31 PM »
As always, Thank you Linda!
If you are doing an itemized statement for the patient as requested by them because they want to submit to their insurance to try to seek some reimbursement  and they only are requesting an itemized statement of the therapy sessions provided directly by the therapist "Is it wrong to not show the other charges that would not be reimbursed by the insurance or do a full itemized statement of everything even if you know the insurance is going to deny it". 
Say it is RTC program, private pay, cash upfront and OON; The program tried to get it covered by the insurance upon admissions but it was denied because of medical necessity but the patient wants a separate itemized statement showing only the therapy sessions that were provided directly by the therapist so they can submit to their insurance to try to seek reimbursement for those sessions only. Can you provide them with just that? or does it need to show the other charges such as room and board if it is all inclusive in the $375 day rate. Sorry if I am confusing you, I am confused myself!

PMRNC

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Re: 2 separate FEE schedules for ONE OFFICE
« Reply #5 on: January 16, 2012, 04:36:42 PM »
Quote
If you are doing an itemized statement for the patient as requested by them because they want to submit to their insurance to try to seek some reimbursement  and they only are requesting an itemized statement of the therapy sessions provided directly by the therapist "Is it wrong to not show the other charges that would not be reimbursed by the insurance or do a full itemized statement of everything even if you know the insurance is going to deny it".

Full itemized billing statement.. CYA :)

Quote
Say it is RTC program, private pay, cash upfront and OON; The program tried to get it covered by the insurance upon admissions but it was denied because of medical necessity but the patient wants a separate itemized statement showing only the therapy sessions that were provided directly by the therapist so they can submit to their insurance to try to seek reimbursement for those sessions only. Can you provide them with just that? or does it need to show the other charges such as room and board if it is all inclusive in the $375 day rate. Sorry if I am confusing you, I am confused myself!

Not sure why they want you to leave off charges, sounds fishy but I would still again say, show all charges. Insurance will pay their portion. Make sure you not only show the full charges but any payments and/or discounts given, full disclosure is the better way to be safe rather than sorry.   You might be dealing with someone who is hoping insurance company is picking these up as individual sessions but if they are room/board/inpatient charges they probably have a cap on days.. so what they might be wanting is a way to get carrier to pay them as reg outpatient services.. NOPE.. can't do it. don't do it. Give them an itemized bill, collect the portion you know they are responsible for and wash your hands :) JMO
Linda Walker
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Angie

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Re: 2 separate FEE schedules for ONE OFFICE
« Reply #6 on: January 16, 2012, 04:56:20 PM »
That's what it is. The insurance has denied the Residentail Treatment so the patient wants to see if their insurance will reimburse them for the therapy sessions only rather than the daily rate that was denied. So they want an itemized statement of the inpatient individual therapy sessions only but with the inpatient RTC codes (90818).......

PMRNC

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Re: 2 separate FEE schedules for ONE OFFICE
« Reply #7 on: January 16, 2012, 06:06:12 PM »
Oh that's def a no no.. IF THE PLAN IS DENYING because they met the inpatient max (may have been with another treatment facility)..  Either way.. that won't be YOUR problem so LONG as your bill reflects the important things.. that it was residential treatment and/or inpatient.. because you do NOT want to mislead the carrier into thinking the patient went in for outpatient therapy.  POS 55 or 56 should be visible on the billing statement. 
Linda Walker
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Angie

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Re: 2 separate FEE schedules for ONE OFFICE
« Reply #8 on: January 16, 2012, 06:58:08 PM »
The plan denied because of clinical; the patient didn't meet their criteria for residential treatment, it went to a Dr to Dr and was denied.
So as long as I put the proper coding the 55 or 56 and the inpatient therapy like Individual 90818 (I have the therapy notes to back it up with) I can provide the patient with that statement of just the therapies  w/o the room and board even though it is all inclusive? It is kind of like unbundling the services; which I don't fully understand........
Some have said you cannot unbundle and some have said you can.....
I don't want to mislead the insurance at all..... The patient is instant that we provide him with this, and he submit it and receive payment from his insurance as he has already paid in full and we are not contracted with the insurance......

PMRNC

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Re: 2 separate FEE schedules for ONE OFFICE
« Reply #9 on: January 17, 2012, 07:30:18 AM »
Ok, I have a better understanding.. sorry for being so dense.  Here is what I would do. I would give the patient the SAME bill that you normally give out. When they submit to their insurance the insurance will either pay/deny/unbundled.  Break out the services, use the right POS, CPT codes, DX codes. When the patient gets the EOB and if there is a denial, ask them to bring it in and you can look at it.  Then it's not on you, you are in the free/clear.  BTW, if patient wants something different than what you would normally give out, or they want you to change something, just tell them "No" but tell them you'll be happy to look at their EOB's and you can explain better to them. Tell them your not allowed to change the billing to suit their insurance needs.
Linda Walker
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Angie

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Re: 2 separate FEE schedules for ONE OFFICE
« Reply #10 on: January 17, 2012, 08:58:49 AM »
Thank you Linda for all of your help!

Angie

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Re: 2 separate FEE schedules for ONE OFFICE
« Reply #11 on: January 17, 2012, 01:29:19 PM »
Linda when I am providing them with a super bill and there are no codes for a service provided how do I put that on an itemized statement for the patient so that they can submit it to their insurance to see what portion the insurance may reimburse them for? (This is all inclusive, private pay and the family is wanting an itemized statement so they can submit it to their insurance to see what portion of the program the insurance may reimburse them)
I know how to list and code the Individual Sessions with the licensed therapist (have notes for those) but for instance the family weekly calls that the therapist provides each week. The therapist calls the family weekly to provide them with a summary of the patients week, family feedback, discussing aftercare, etc.....This is done over the phone and not really a "family therapy session" per say..... There are no codes for this so any advise on how to list it on a superbill?????

PMRNC

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Re: 2 separate FEE schedules for ONE OFFICE
« Reply #12 on: January 17, 2012, 04:15:48 PM »
What I think you are trying to do is admirable to help the patient, however your facility does not participate in insurance billing/claims.. With that said, here is what I believe you should do and what I would do. I would give them the same bill that you would give any other patient and let them fight with their insurance companies, it's really out of your hands at this point. If you really think you need to do this then all I can suggest is that you take the time and code things as much as possible and the services with no codes you should itemize and use the 99999 CPT. 

I'm sure since your facility is non insurance, you guys have a policy that patient's see up front?
Linda Walker
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Angie

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Re: 2 separate FEE schedules for ONE OFFICE
« Reply #13 on: January 17, 2012, 04:45:03 PM »
Yes we most defiantly do have a policy in place but you would not believe the amount of requests (demands) that we get for this.... I can provide them with a UB04 but there is no code for "Wilderness Program" and we cannot code it as Residentail Treatment even though they are in our care 24/7 because we don't meet the criteria for RTC; no building with beds, no RN on site 24/7 etc....... If we did provide them with a UB04 would there be an appropriate rev code for Therapeutic Wilderness Program do you think? There is a billing company here locally that I know does some of this and they use the Residential Treatment code even though they are not licensed as such and she insists she can do this because there is no code for Wilderness Programs that she has to use the closest code but that does not seem very ethical to me and seems really misleading to the insurance (even though it will get denied because they don't cover wilderness programs in the end and once they review the records they will see this but she will appeal it, that is what she does).....but I am a bit anal and tend to be more conservative I guess!

PMRNC

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Re: 2 separate FEE schedules for ONE OFFICE
« Reply #14 on: January 17, 2012, 05:00:06 PM »
Ok, so what would happen if you refer the patient back to that policy they obviously have seen and signed and tell them you would be happy to give them a copy of the bill and just give them what you would normally give them. Period?   I think you have to draw line because technically your not following your own policies and procedures.   Tell the patient, I'm sorry but this is all we provide, as per the policy to which you seen at the beginning of treatment.   I think you'll be stress free, <G> JMO.   It can't be a surprise to them. If your financial policy doesn't include anything about the patient's bill. Add it in there, put in there that they will receive the offices billing statement as available and that's it.
Linda Walker
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