Author Topic: out of network provider  (Read 4889 times)

Medicare56

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Re: out of network provider
« Reply #15 on: April 30, 2013, 04:17:07 PM »
so basically, we have to then ask the patient to pay us the money? It is assumed that if the assignment is not accepted then the carrier won't pay for the supply anyway right?

PMRNC

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Re: out of network provider
« Reply #16 on: April 30, 2013, 04:43:02 PM »
Quote
so basically, we have to then ask the patient to pay us the money? It is assumed that if the assignment is not accepted then the carrier won't pay for the supply anyway right?

Your scenario might be different.   We were talking about Assignment of Benefits and NON par providers where the carrier reimburses the patient.  No, you can't assume because an assignment of benefits was not honored that the service wasn't covered. These are completely different things.
Linda Walker
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best biller

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Re: out of network provider
« Reply #17 on: May 02, 2013, 06:13:20 PM »
can anyone help me and let me know where i can get the aob?

PMRNC

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Re: out of network provider
« Reply #18 on: May 02, 2013, 06:16:45 PM »
The AOB is Assignment of Benefits and should be a part of your office financial policy the patient signs, it should be a separate section for them to sign to assign benefits. If the office had one it should be in the patient's file, if not you will need the patient to sign one next time they come in. You can try and send them one to file but it won't help for claims already filed w/out an AOB.
Linda Walker
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RichardP

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Re: out of network provider
« Reply #19 on: May 06, 2013, 02:13:37 PM »
If there is full payment in the payment field of the CMS1500 but yet there is an assignment of benefits, one had better exist but again, I'm not sure WHY a patient would assign benefits if they have paid for services.

1.  My initial response was to the specific question - would United Healthcare send payment to the provider when he was not a participating provider?  My response was direct: we have a provider who is non-participating with United Healthcare, his patients have signed an Assignment of Benefits, and United Healtcare does send the payment directly to the provider.  When I said that, I was only confirming that United Healthcare in California does send payment to a non-participating provider.  I was not laying out the details of how that worked.

2.  Linda's questions ask to clarify an issue separate from the original question I was answering.  She was correct to bring this up for purposes of clarification - I just didn't understand what she was asking initially.  So -

a.  We do have an Assignment of Benefits on file for each patient where we print "Signature on File" in Box 13 of the CMS 1500.  We never intentionally send a CMS 1500 with "Signature on File" in Box 13 of the CMS 1500 when we actually have no such signature.  If there is full payment, or partial payment, for services, we account for that.  See Point 2(c) below.

b.  Why would the patients sign an Assignment of Benefits with a non-participating provider?  I don't know.  But they do.  Up until recently, the patients filed their own insurance.  We have only recently begun billing as a courtesy to the patients.  The provider may ultimately discover that the assignment of benefits to the non-participating provider, and the providing of refunds to patients when due, might be more hassel than it is worth and drop it.

c.   "Cash Only" is the objective.  Partial payment is the reality in most cases.  If we are informed that payment has been made before the CMS 1500 is completed and submitted to the Insurance Carrier, the amount of payment shows up in Box 29 of the CMS 1500.  If we are not told that payment has been made, we can't know.  We are operating in real time, not in theory.  If payment of 100% is made, and we are told in time, Box 13 is blanked out, Box 30 = 0 due to the provider, and the Insurance Carrier sends any payment due directly to the patient.

Keep in mind that, as a non-participating provider, the doctor's charges are considerably higher than what the insurance company will pay.  So, if patient pays less than 100% of what is owed, and we are not notified of this, so that we bill the carrier for 100% of the charges, the patient often will still owe money to the doctor after the insurance pays.  Each patient's situation is different.  And billing for each patient involves some combination of office visit, in-house labs (high complexity), x-ray, ultra-sound, and bone density scanning.  It is not simple medicine; therefore it is not simple, cookie-cutter billing.
« Last Edit: May 06, 2013, 02:18:30 PM by RichardP »