Author Topic: Immunizations and Insurance  (Read 3431 times)

GCPH

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Immunizations and Insurance
« on: July 12, 2012, 05:00:24 PM »
Hello,
We are a small Public Health agency, and we are looking to start billing for immunizations.  We have a few questions regarding private insurance.

We currently hold immunization clinics offsite for local employers.  (The plumber wants all his employees to have Hep A shots.  We go to the office and provide shots.  We bill the plumber directly, and he pays for the shots.) 

Right now we do not bill ANY insurance companies.  Our question is, if we start billing private insurance companies (for our walk-in and well child clinics,) would we still be able to hold employer clinics like above, or would we have to bill insurance for each employee?  Is it an all or nothing deal, or does it depend on insurance in/out of network status?  (We get in-network with BCBS and not Cigna. 7 out of 10 of his employees have BCBS.  We bill BCBS for those employees, and we bill the employer for the other 3 Cigna employees)

Thank you for your help with this.  We are so new to the billing world. 
Thank you!!!




PMRNC

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Re: Immunizations and Insurance
« Reply #1 on: July 12, 2012, 05:14:23 PM »
If you credential with carriers you won't be able to pick and choose who goes through insurance and who doesn't. That's the idea of signing the contract with the carrier, you will get up to the approved rate and every patient is responsibly for their copay. You could work it out to the employer to pay the copay instead, just so long as your NOT making more than the allowable rate for the participating carrier. For example, if your shot is $80 and the carrier approves $60 and patient has a $10 copay, you could have the employer pay the copay's so you'll be getting $70 per $80 shot.   You also can not arbitrarily waive patient out of pocket either, patient's must mee their cost sharing obligations under their plan unless there is a documented hardship.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

GCPH

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Re: Immunizations and Insurance
« Reply #2 on: July 12, 2012, 05:42:47 PM »
I was afraid of that.  Thank you so much for your assistance on this.  I've learned more in the past 2 days on this site, than 6 months of research on my own.

Thank you!
-a

PMRNC

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Re: Immunizations and Insurance
« Reply #3 on: July 12, 2012, 06:27:11 PM »
Your very welcome :)
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

DMK

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Re: Immunizations and Insurance
« Reply #4 on: July 13, 2012, 10:08:56 AM »
And don't stop reading and checking into this site!  I read EVERY post and get a nugget of information every time!

PMRNC

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Re: Immunizations and Insurance
« Reply #5 on: July 13, 2012, 05:08:16 PM »

Quote
And don't stop reading and checking into this site!  I read EVERY post and get a nugget of information every time!

She gets nuggets but she gives boulders :)
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

DMK

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Re: Immunizations and Insurance
« Reply #6 on: July 13, 2012, 06:52:04 PM »
That made my day/week/month coming from you!!!!

sandyb52

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Re: Immunizations and Insurance
« Reply #7 on: August 13, 2012, 02:43:33 PM »
Hello, I would like to confirm that I understand correctly, is it that if we are contracted with an insurance company and a patient comes in with that insurance we must charge the insurance, even if the patient wanted to pay cash? 

We are a small medical clinic and our policy and procedures manual states that we offer 15 minute office visits for $50 cash.  We also bill insurances but sometimes the patient will actually end up paying more if we bill the insurance.  Do we have a choice to accept the $50 cash price or must we bill the insurance?  If we are not contracted with an insurance company are the rules the same?

Are we allowed to discontinue taking new insurance patients and just charge the 15 minute cash price if we feel we are becoming overwhelmed with insurance billings?

I thank you so much for your help!!

PMRNC

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Re: Immunizations and Insurance
« Reply #8 on: August 14, 2012, 09:44:37 AM »
Quote
Hello, I would like to confirm that I understand correctly, is it that if we are contracted with an insurance company and a patient comes in with that insurance we must charge the insurance, even if the patient wanted to pay cash?

We are a small medical clinic and our policy and procedures manual states that we offer 15 minute office visits for $50 cash.  We also bill insurances but sometimes the patient will actually end up paying more if we bill the insurance.  Do we have a choice to accept the $50 cash price or must we bill the insurance?  If we are not contracted with an insurance company are the rules the same?

Are we allowed to discontinue taking new insurance patients and just charge the 15 minute cash price if we feel we are becoming overwhelmed with insurance billings?

I thank you so much for your help!!

No, if you are contracted with a carrier you cannot arbitrarily work around them, you must bill them, collect the cost shared copay/coinsurance/deductibles from the patient.  Not only is it in violation of YOUR contract with the provider NOT to do so, but it's a violation of the contract between the insured and the carrier as well.

If you are contracted with a carrier your contract will include the stipulations you are bound to in regards to taking new patients. You must follow those guidelines and not just arbitrarily decide not to take any more from that carrier, that's highly unethical.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

sandyb52

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Re: Immunizations and Insurance
« Reply #9 on: August 14, 2012, 11:13:36 PM »
Thank you so much for this information!  I am new to this billing world and have been receiving advice, some of which seems to not be so valid - my first thought was to post this question and I am soooo glad I did, what a service you are performing, I hope to have the opportunity to pass it forward and do the same for another person!