Patient Financial Agreements

[mpl]

Hello!

I'm billing for a mental health provider based in WI. We have a client with a commercial policy that has a large deductible. The provider has asked me to bill the service at the regular $150 rate, but wants to only charge the client $80 with the intention of writing off the rest, due to financial hardship. Clearly this is fraudulent and I won't be able to do this, but I still have some of questions...

1. Can the provider bill the insurance $80 for now (so that it will still go toward the deductible accumulation), and then once the deductible is met, go back to her regular rate of $150? The provider is contracted with this insurance company, so I suspect the answer to this is a sound NO. Or maybe it depends on what the contract says??
2. Can the provider see this client on a cash basis for $80 for now (not billing insurance anything), and then when the deductible is met, charge the regular $150 rate and start billing to insurance? Assuming that a signed financial agreement outlining this would have to be in place, especially since the provider is contracted with the insurance company.

I don't want to put either my business or the provider at risk by doing anything fraudulent or shady, but I also want to see if there are any options for providers when they are trying to help a client out in this type of situation. I'm sure this is a question that I should already know the answer to, but hoping that someone can fill me in, and possibly offer some advice for an alternative way (if there is one) to handle fee discounts due to financial hardship.

Thanks so much!

[Michele]

1. Can the provider bill the insurance $80 for now (so that it will still go toward the deductible accumulation), and then once the deductible is met, go back to her regular rate of $150? The provider is contracted with this insurance company, so I suspect the answer to this is a sound NO. Or maybe it depends on what the contract says??

No because they would be billing all other clients the $150 for the same service.

2. Can the provider see this client on a cash basis for $80 for now (not billing insurance anything), and then when the deductible is met, charge the regular $150 rate and start billing to insurance? Assuming that a signed financial agreement outlining this would have to be in place, especially since the provider is contracted with the insurance company.

The patient can opt not to use insurance however it will be harder for them to meet the deductible if the claims are not being submitted.


If the patient has a financial hardship the provider can document the financial hardship in the chart and give a discount after the claims are processed, but it must be a valid hardship and it must be documented.  I cannot advise you legally on this, but I wanted to mention it.

[AGOG]

The provider should have criteria set up for the indigent and charity care option in his Personnel Manual or bylaws. He can write off for the hardship of some percent (otherwise specify in his personnel manual) of the patient's responsibility. You just have to prove that the patient is having the hardship to pay the bills. Get patient to signed those hardship waiver form from your facility. and keep it on file.