Author Topic: Predetermination patient responsibility  (Read 2636 times)

Cpatel

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Predetermination patient responsibility
« on: June 05, 2015, 10:41:23 AM »
Hello!

Recently I came across two Medical Practices who determine patient responsibility (out of pocket expense and deductible) prior to service based on for what reason patient will be seen and they collect from patient in front. Is anyone aware of such a software which can give us pre estimate for patient deductible and out of pocket responsibility based on CPT code? Please share this information.

I am aware that if it is straight office visit then it will be fixed copay but it is hard to figure out the actual deductible or out of pocket expense on specific CPT.


Thanks

Merry

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Re: Predetermination patient responsibility
« Reply #1 on: June 05, 2015, 10:49:16 AM »
Verification through the insurance co. If you use a clearing house see if they offer the service. Or some Co have automated services but remember pre-determination and even pre auths is never a guarantee that the claim will be paid.

kristin

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Re: Predetermination patient responsibility
« Reply #2 on: June 05, 2015, 07:04:17 PM »
Actually, there are plans that don't have a fixed co-pay for an office visit, instead it is a co-insurance amount.

As Merry replied, there are several ways to determine what a patient's benefits are ahead of time. There are also websites such as Navinet and Availity to figure it out. But in order to know what to charge the patient, you have to know what the fee schedule is for each payer, for each CPT code that is being billed. How do the offices know BEFORE the patient is being seen what the charges will be? I am thinking in particular about E/M codes 992XX...there is no way to know what level visit will be charged without seeing the patient first.

Also, some insurance contracts with providers prohibit them from collecting money up-front from patients(other than co-pays), so be careful with this.

PMRNC

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Re: Predetermination patient responsibility
« Reply #3 on: June 06, 2015, 08:00:58 AM »
Quote
Is anyone aware of such a software which can give us pre estimate for patient deductible and out of pocket responsibility based on CPT code?

Wow, I'd buy it. LOL  seriously.. no software can do this. you might be thinking of a pre-determination of benefits and I have seen software that will put one out for you. It's a form that goes the insurance carrier (usually only on high dollar claims) before the services are rendered with the  physician's fee and the carrier will tell you yes or no it's within R&C and some will give you the deductible, coinsurance and any copay. Like I said these are really only used for high dollar surgical claims where you know the procedure ahead of time and want to find out if it's within U&C.

Others mentioned the clearinghouses and services.. I do my own via phone.. I have timed this process and I think it takes longer sometimes, so I stick with the good ol fashioned phone.
Linda Walker
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Cpatel

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Re: Predetermination patient responsibility
« Reply #4 on: June 08, 2015, 07:37:57 AM »
Thanks for reply and I do agree with all of you, but it happened with me recently. I went to one of the specialist for first time. While making the appointment they asked me why I want to see XYZ specialist and I gave the information about my condition. When I went for my appointment I was given XYZ software's pad to enter all the information and at the end it asked me the payment of xxx amt as my responsibility for service. It was not a fixed copay. I was surprised and asked to frond desk rep that how did they figured out that what level of services will be billed to insurance without even seeing the doctor. She said based on the problems I told over the phone at time of appointment, Dr. has predetermined the level of services. As a Biller I am aware that except copay, it is not legal to collect from patient prior to services so I called my insurance after the service and advised them that Physician collected in front. Insurance rep advised that Physician's are allowed to do so. I was very surprised to hear that.

So, I thought to share this with other billers as we all work hard to collect from patients after insurance process the claim. I have contacted my clearing house to see if they carry any product to predetermine the patient responsibility.


PMRNC

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Re: Predetermination patient responsibility
« Reply #5 on: June 08, 2015, 08:51:11 AM »
From doing some google searches I came across a software based overseas I believe does real-time eligibility and verification benefits  www.intake.io it looks like a standalone and has place for patient to enter demographics from an Ipad.

NOW.. as far as collecting BEFORE the visit.. I have a problem with this and I believe you could easily make a case out of it. Most insurance polices have their cost provisions in their summary benefit plan book that will specifically say "at time of visit". Same with physician contracts with carriers and I'd be sure to bet taking copay before a visit would in fact violate some of those contracts. I personally would NEVER pay my copay until checkout. I took my daughter to a dermatologist (only one in a 100 mile radius) who wanted our copay and deductible up front. I had no choice, I paid it and then we sat in the office for 3 HOURS to see the doctor.. I went up to the desk and told them I wanted my check back or I'd walk out and go straight to the bank and stop payment. She handed me back the check and said she would have to re-schedule the visit.  :o :o :o  upon talking to other patients in the wait area, this doctor does that because he can because he's only dermatologist in a 100 mile radius.. well that's ok, not THIS patient. Ended up going to another state to see a doctor. From my point of view that doctor owed ME money for sitting there for 3 hours!
Linda Walker
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Cpatel

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Re: Predetermination patient responsibility
« Reply #6 on: June 08, 2015, 11:43:27 AM »
From doing some google searches I came across a software based overseas I believe does real-time eligibility and verification benefits  www.intake.io it looks like a standalone and has place for patient to enter demographics from an Ipad.

NOW.. as far as collecting BEFORE the visit.. I have a problem with this and I believe you could easily make a case out of it. Most insurance polices have their cost provisions in their summary benefit plan book that will specifically say "at time of visit". Same with physician contracts with carriers and I'd be sure to bet taking copay before a visit would in fact violate some of those contracts. I personally would NEVER pay my copay until checkout. I took my daughter to a dermatologist (only one in a 100 mile radius) who wanted our copay and deductible up front. I had no choice, I paid it and then we sat in the office for 3 HOURS to see the doctor.. I went up to the desk and told them I wanted my check back or I'd walk out and go straight to the bank and stop payment. She handed me back the check and said she would have to re-schedule the visit.  :o :o :o  upon talking to other patients in the wait area, this doctor does that because he can because he's only dermatologist in a 100 mile radius.. well that's ok, not THIS patient. Ended up going to another state to see a doctor. From my point of view that doctor owed ME money for sitting there for 3 hours!

Thanks Linda. I will do some research.

kristin

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Re: Predetermination patient responsibility
« Reply #7 on: June 08, 2015, 07:16:29 PM »
Quote
I was surprised and asked to frond desk rep that how did they figured out that what level of services will be billed to insurance without even seeing the doctor. She said based on the problems I told over the phone at time of appointment, Dr. has predetermined the level of services.

This is just wrong, wrong, wrong. I would never see a doctor who does this. If they are doing something like this, I wouldn't want to know what else they are doing that is wrong. I couldn't trust an office/doctor with that kind of policy in place.

As for what the insurance rep told you, do you think maybe they were confused by what was being collected before the services were rendered? A co-pay is one thing, but a level of service allowed amount is something else.

PMRNC

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Re: Predetermination patient responsibility
« Reply #8 on: June 09, 2015, 10:05:47 AM »
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As for what the insurance rep told you, do you think maybe they were confused by what was being collected before the services were rendered? A co-pay is one thing, but a level of service allowed amount is something else.

There are managed care plans that have copay's based on level of services. For example a straightforward office visit might have copay of $10 where a blood draw or immunizations etc, might have no copay. (just an example). Before my own plan change in Jan I had a level of service copay where I only had a copay for the intial visit, none for subsequent, there was a copay for labs, none for surgical.. etc. Usually your big companies with various levels offer these plans and employee chooses.
I THINK that's what the original poster was talking about.
Linda Walker
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www.billerswebsite.com

Cpatel

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Re: Predetermination patient responsibility
« Reply #9 on: June 11, 2015, 07:11:04 AM »

This is just wrong, wrong, wrong. I would never see a doctor who does this. If they are doing something like this, I wouldn't want to know what else they are doing that is wrong. I couldn't trust an office/doctor with that kind of policy in place.

As for what the insurance rep told you, do you think maybe they were confused by what was being collected before the services were rendered? A co-pay is one thing, but a level of service allowed amount is something else.

I agree with you. I have high deductible plan so doc's office rep said they are collecting deductible and I specifically asked that how can you determine the level of service without patient being seen by the doctor. Rep said that doc decide level of service based on the problems mentioned at time of appointment. We all know that doctor's do not have time to go over the scheduler and also no doc can predetermine the level of service without examine the patient. When I called insurance, they did not had the claim on file so rep just gave me generic information that providers are allowed to collect deductibles in front.