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Mental Health Billing

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PMRNC:
This is a rather grey area because technically you MUST show the discount and give same discount to the carrier as you would the patient. With THAT said:
Show all your discounts to the carriers and to the patient. For example if you are billing the carrier 20 days @ $400 per day = $8000.00 now the carrier is only going to pay the allowable for the 10 days so there will be $4000 left.  Showing the discount might technically lower the reimbursement but legally that's how it is supposed to go.

A patient's out of pocket expenses are a part of the "cost sharing" provision of their contract with the insurer, by manipulating that fee with a discount you are giving to patient but NOT the carrier, that is legally a breach of contract.  So this is how it COULD go..  let's say carrier pays 80% of the $4000 (10 days) and they pay $3200 (not sure you said this was participating carrier in which case the $800 would either be a par adjustment OR patient responsibility (I'm only using the 80% as example).     

Even though the carrier only pays for 10 days, the left over days/amount is still considered patient out of pocket.  I know this really doesn't answer your question..but my advice would be to get the balance (after discount amount) from the patient up-front and show it as paid on the claim. Also refer to the office policy for discounts, if you only offer discounts to cash patients, then I would say you shouldn't discount this UNLESS patient pays the out of pocket first.

Angie:
Linda so even though we are not contracted with any of the insurance companies (we are located in UT) we cannot bill our daily rate of $400 a day to the insurance while the insurance has authorized those days and then after they deny and are not going to fund any longer we cannot give the parents a discout at the $300 a day per the addendum to the patients contract for no insurance as we give a reduced rate for cash patients?
Say the insurance authorized 10 days. The parents don't pay for those 10 days we just bill the insurance 10 days at $400 a day then on the 11th day when the insurance has denied services we would reduce the rate to $300 a day for cash patients and the account goes private pay.
Sorry if this does not make sense...I'm trying...... :-\
Any advice????

midwifebiller:
Most of our 50+ providers are out-of-network (OON).  There are a couple of gray areas with OON providers, so we consulted an insurance attorney, who in turn consulted with his peer group on this matter.

If you know the insurance company will not reimburse a service, there is no need to send a claim.  After the authorized claims have been sent, you can then change the account to private pay and offer a discount.

Angie:
Thank you for the information!
Do we have to collect what the insurance does not pay from the patient since we are out of network and do not have a contract?
Say we bill $4000 and they only allow $3000; can we write off the difference as an Adm adj or do we have to collect that from the patient?

PMRNC:
Kelli, I agree.. I was told same thing..  THEIR problem is that they KNOW the insurance will only pay portion..they want to write-off the rest or partially write off (discount) but if they do it "routinely" I'm still seeing this as a problem  ::)

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