Author Topic: UNLAWFUL CHARGING???  (Read 3464 times)

aremy44

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UNLAWFUL CHARGING???
« on: May 08, 2015, 01:59:58 PM »
Is a physician who is not contracted with Tricare or any other insurance except Medicare required to reimburse a Tricare patient who came to  him and self paid for services? the patient was aware of the fees upfront when he came in for an appointment and we billed Tricare as a courtesty as we do for all our patients. But now after getting reimbursed he is stating that according to Tricare he was only responsible for 15% above the allowable and that the physician has to reimburse the rest. Has anyone heard of this? Is it true?

RichardP

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Re: UNLAWFUL CHARGING???
« Reply #1 on: May 08, 2015, 02:51:26 PM »
See the heading Non-Participating Providers ... at the bottom of this link.

http://www.tricare.mil/FindDoctor/NonNetwork.aspx

Specifically:

The provider has the legal right to charge up to 15% of the TRICARE allowable charge. Any charges above the allowable charge are your responsibility and will not be reimbursed.

Tricare may pay up to 115% of their allowable charge.  Patient is responsible for any monies due above that 115%.

If this wasn't explained to the patient by your office, you can still insist that the patient pay.  But, if you do that, and patient bad-mouths your business, it may not be worth it in the long run.

aremy44

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Re: UNLAWFUL CHARGING???
« Reply #2 on: May 11, 2015, 07:48:45 AM »
Thank you for that response, however that leads me to another question. Since the fees my physician charges are way above the 15% increase over the allowable, is my physician doing something illegal? I was under the impression that a physician would have to apply to be a certified or authorized Tricare provider. We have no such application on file here, and what is worse I was told that simply because the physician filed a claim on behalf of a Tricare patient he is now considered authorized and is bound by their rules. This is essentially like roping a physician into accepting their insurance benefits. How can this be? For other commercial insurances they pay what they allow and basically the patient has the responsibility of paying whatever their insurance does not cover. In a private contract between the patient and physician how does the physician end up having to reimburse the patient after insurance has already reimbursed their portion to the patient?

RichardP

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Re: UNLAWFUL CHARGING???
« Reply #3 on: May 11, 2015, 09:32:57 AM »
I was under the impression that a physician would have to apply to be a certified or authorized Tricare provider.

Your statement is correct:  ... to be a certified or authorized Tricare provider.

But not all providers are authorized to be part of the Tricare network.

In the link I provided, Tricare makes it clear that the patient is not required to see an authorized Tricare provider.  However, if they do see a doctor that is NOT an authorized Tricare provider, the patient is responsible for any charges above 115% of Tricare's allowable amount.

aremy44

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Re: UNLAWFUL CHARGING???
« Reply #4 on: May 11, 2015, 11:43:21 AM »
You have made me a very happy camper today. I thank you and so does my physician. Thanks a bunch. ;D

aremy44

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Re: UNLAWFUL CHARGING???
« Reply #5 on: May 11, 2015, 01:53:28 PM »
I was elated, but now some new information has me a bit baffled once again. I found a letter from Tricare stating that our provider was no longer an authorized Tricare provider as of 2002, but he has been accepting Tricare payments as of that date from patients who have Tricare as a secondary to Medicare (whom he is contracted with). Does such a letter affect his status with Tricare as a secondary?

RichardP

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Re: UNLAWFUL CHARGING???
« Reply #6 on: May 11, 2015, 02:25:30 PM »
If he is not contracted with Tricare, he is not contracted with Tricare.  Period.  Unless there is some formal agreement to the contrary, it doesn't matter whether the patient has Tricare as primary or secondary.  Your provided is not contracted with Tricare.

rdmoore2003

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Re: UNLAWFUL CHARGING???
« Reply #7 on: May 11, 2015, 04:59:14 PM »
Are you accepting assignments on these claims?
Regina

aremy44

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Re: UNLAWFUL CHARGING???
« Reply #8 on: May 12, 2015, 08:06:18 AM »
Regina, the only time he accepts assignment is when Tricare is secondary to Medicare. After finding a letter yesterday from Tricare stating that he is no longer an authorized provider; it raised the concern that he has been accepting payment from them for the last 13 years. Can they legally request the monies that they paid out to him back?

PMRNC

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Re: UNLAWFUL CHARGING???
« Reply #9 on: May 12, 2015, 08:43:20 AM »
I know it's possible, but doubtful that they would go on and pay him for 13 years..So, I'm thinking there was a contract somewhere within those 13 years. Maybe the letter is old and after that somehow he contracted with again? I'm thinking there is a par contract somewhere someone is overlooking. Call Tricare provider relations ASAP to confirm. IF they did pay him as non contracted provider, well they could ask for monies back, however if I were the provider I would counter/appeal that legally as they set the precedence and it could be past a statute of limitations or recoupment period. Not sure..but I would def call them and find out ASAP
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

aremy44

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Re: UNLAWFUL CHARGING???
« Reply #10 on: May 12, 2015, 11:21:04 AM »
Linda, my physician isn't contracted with any commercial insurance, however he does get paid from our Medicare patients secondary insurance. Wouldn't Tricare fall into this category? If he would have to pay back monies paid to him from Tricare, why would he not be bound to pay back monies paid to him by other commerical insurance companies whom Medicare forwards claims to once they have paid...?

PMRNC

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Re: UNLAWFUL CHARGING???
« Reply #11 on: May 12, 2015, 12:19:46 PM »
Quote
Linda, my physician isn't contracted with any commercial insurance, however he does get paid from our Medicare patients secondary insurance. Wouldn't Tricare fall into this category? If he would have to pay back monies paid to him from Tricare, why would he not be bound to pay back monies paid to him by other commerical insurance companies whom Medicare forwards claims to once they have paid...
?

Tricare is NOT a commercial carrier/plan.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com