Billing > Billing

Discounting a Non-Covered Service to a pt that has insurance

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Michele:
I've actually seen a few plans like this.  We have called and been advised that office visits aren't covered under their plan.  I'm like "If you don't cover office visits then what do you cover?"  They usually cover hospitalization, surgeries, and other things, but not office visits. 

So they are processing the claim, showing the Anthem allowed amount, but not making any payment since it is not a covered benefit under the plan.  But the provider is required, since they are a participating provider to accept the allowed amount, even though it is not being applied to a deductible or out of pocket.  My opinion is that if you are billing patient for the allowed amount, but offering a prompt pay discount, that is ok.

Michele

Pay_My_Claims:
OK, I think I can get it. Anthem DOES pay for office visit, however the Anthem plan they have is basically a hospital policy. Since they do have an allowed amount for office visits, they have to accept that allowable because they are a par provider, even though they have no coverage.

PMRNC:
No No no.. If this is indeed a hospitalization ONLY Plan (catastrophic coverage) they are not going to "allow" anything, this does not mean the doctor eats the charge. The plan is not a true major med plan, therefore it should be treated as "no coverage", regardless of par status. There should be NO allowable since they wouldn't have a fee schedule for office visits on a hospitalization plan. The doctor is able in that situation to collect the full fee. When and if benefits were verified this would have pre-established this for the patient.
If the patient protests, you merely would refer them to their policy booklet which would explain what their policy covers.
It wouldn't be reasonable to expect to go to the doctors and have your insurance pay for the visit when your insurance only covers surgical and hospital procedures.
Now again, this is for hospitalization and/or catastrophic plans.. we don't know for sure if that's the case here.

Michele:
Actually, there question was if it was ok to offer a prompt pay discount, an amount lower than the allowed amount.  Based on all that you said, I think I was ok with my previous response stating they can indeed offer a discount, right?

Michele

PMRNC:
Yes, I would think it would be ok. I'm sorry I should have gone back to read the original question!  ???
I would think if they have other patients with same coverage though they might want to cover themselves with a financial hardship agreement? Or I could be overthinking today.

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