Author Topic: Discounting patient responsibility for non par insurances  (Read 3808 times)

paulette

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Discounting patient responsibility for non par insurances
« on: February 21, 2009, 12:15:48 PM »
Is is acceptable to discount the amount we bill a patient when his/her plan is out of network as long as we have a set discount or set flat fee for all patients?  For example - we receive $0 - EOB states patient owes $600 - can we discount patient balance to $400?  It only makes sense that the non par insurance carriers can not dictate what we actually accept from the patient.  Are there any known state laws that would govern this practice?


Michele

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Re: Discounting patient responsibility for non par insurances
« Reply #1 on: February 21, 2009, 10:00:09 PM »
Technically you are not supposed to charge a patient a lower amount than you charged the insurance carrier, even if you are not in network.  They can't dictate what you can charge, but you are not supposed to charge different amounts.  There are a couple of reasons behind it.  For example, if the patient has a deductible and you bill the insurance $600, they apply the whole $600 to the patient's deductible, and then you only charge $400.  But $600 was applied to the deductible. 

If you are going to accept less than you submitted to the insurance carrier then you need to document the patient's chart as to why.

Michele
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Pay_My_Claims

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Re: Discounting patient responsibility for non par insurances
« Reply #2 on: February 21, 2009, 10:23:11 PM »
I don't view it as charging less, but I wouldn't just offer up a discount either. Being non-par only means that you can balance bill the patient. You don't have to, but if you choose to you can. You can adjust off whats considered non-allowed by the carrier and bill the client that. EX: Non-par provider bills 600.00 for his services. EOB reads Charge:600.00 Allowed 400.00 ded: 400.00  Pt respons: 600.00 Paid to provider: 0.00
It shows that the patient is responsible for the 600 because although we billed 600.00 the ins company only allowed 400.00 and his deductible was 500.00 Even if we were par the bill would be his, and all he would technically be responsible for is 400.00.  I think charging less would be if a client comes in with insurance and we bill them 600.00 v/s him coming in with none and we charge 400.00 w/o the balance after you bill the insurance in my opinion is called an adjustment. As long as you accept what the in network reimbursement would have been, I can't see that as illegal.

Michele

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Re: Discounting patient responsibility for non par insurances
« Reply #3 on: February 22, 2009, 07:15:48 PM »
I should have been more specific.  What I was referring to was charging the patient less than the allowed amount by the insurance carrier, even if you are non par.  So the example would be:

Charged insurance:   $600.00

Insurance allowed:    $500.00

Applied to deductible: $500.00

Only bill patient:        $400.00


Of course you can choose to only bill the patient the allowed amount even if you are non par. 

Hope I didn't cause any confusion.

Michele
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Pay_My_Claims

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Re: Discounting patient responsibility for non par insurances
« Reply #4 on: February 22, 2009, 08:30:24 PM »
Exactly............we see eye to eye on it too.

paulette

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Re: Discounting patient responsibility for non par insurances
« Reply #5 on: February 24, 2009, 10:39:07 AM »
Thank you so much for the input! 

PMRNC

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Re: Discounting patient responsibility for non par insurances
« Reply #6 on: March 03, 2009, 01:23:26 PM »
With any policy you have to make a reasonable request/attempt for out-of-pocket/balance.
The patient also has a contracted liability with the insurer to pay Out-of-pocket expenses (coinsurance, deductibles)
Linda Walker
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Pay_My_Claims

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Re: Discounting patient responsibility for non par insurances
« Reply #7 on: March 03, 2009, 01:25:19 PM »
With any policy you have to make a reasonable request/attempt for out-of-pocket/balance.
The patient also has a contracted liability with the insurer to pay Out-of-pocket expenses (coinsurance, deductibles)

But of course...we are just speaking on what we can actually bill for.

PMRNC

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Re: Discounting patient responsibility for non par insurances
« Reply #8 on: March 16, 2009, 06:20:54 AM »
I think there is still confusion between "allowed" and "Not allowed"
The example is vague If we are talking "NON PAR"
If the patient has a cost sharing plan the provider does not participate there is still the contract between the insured and the ins company which says the patient is responsible for any "out of pocket".. this includes deductible, coinsurance and non covered charges. Thus just saying the non par plan disallowed an amount is still vague.. why was it cut? U&C?
If they were par the disallowed amount is a write-off / Adjustment.  If it was cut for being over U&C the patient is responsible, they can choose to appeal the charge and the provider can help them attempt the appeal (op report, office notes, etc) and then AFTER reasonable attempt the provider can write-off the non allowed portion.

In the case of billing... IF you know ahead of time what the carrier is paying/allowing on a claim and that you are going to waive the out-of-pocket, that's fraud. We call that TWIPPING (Taking what Insurance Pays) The insurance company had the same right to the same discount which of course then would have reduced the payment (makes sense)

It's not illegal however to waive an occasional patient's balance. An office policy or P&P should be in the office that states the proper way to determine when to waive and how to write-off. Patient's that are hardship cases should complete a financial hardship agreement.

I know this was about billing, but was just concerned others reading would get confused by using the term "allowed"
Linda Walker
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Pay_My_Claims

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Re: Discounting patient responsibility for non par insurances
« Reply #9 on: March 16, 2009, 11:37:33 AM »
What is confusing about it??? The allowed is what the ins company allows for that procedure. If we bill 600 and they allow 500 and the client is covered at 100% (ins paid 500)means I can bill for the other 100 since I am non-par. Non participating, Out of network. If I was a par provider, in network, participating, I would have to adjust off the 100 as a non allowed charge. I have never heard of the term TWIP, but ok, I will definately research that.

PMRNC

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Re: Discounting patient responsibility for non par insurances
« Reply #10 on: March 17, 2009, 06:39:31 AM »
Yes when speaking of a PARTICIPATING PLAN the "Allowed Amount" makes sense as the rest is adjusted off as a par adjustment. However when a plan is "non par" the amount NOT covered has a different reason..the amount being considered is usually based on U&C, NOT fee schedule.
For example, my dermatologist is not par with my carrier.  I had a procedure done last summer in which was billed $800, my carrier "considered" $680 and paid $664 ($16 was not paid due to being above U&C). I was responsible for the remaining $136, if I wanted to appeal the additional $16 that would have been up to me.

I probably am over thinking this.. it's just usually when a plan is NON par they explain the amount not considered and what they do consider is not listed as "allowed amount" only.
Hope that makes better sense.

Linda Walker
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