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2 separate FEE schedules for ONE OFFICE

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PMRNC:

--- Quote ---If you are doing an itemized statement for the patient as requested by them because they want to submit to their insurance to try to seek some reimbursement  and they only are requesting an itemized statement of the therapy sessions provided directly by the therapist "Is it wrong to not show the other charges that would not be reimbursed by the insurance or do a full itemized statement of everything even if you know the insurance is going to deny it".
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Full itemized billing statement.. CYA :)


--- Quote ---Say it is RTC program, private pay, cash upfront and OON; The program tried to get it covered by the insurance upon admissions but it was denied because of medical necessity but the patient wants a separate itemized statement showing only the therapy sessions that were provided directly by the therapist so they can submit to their insurance to try to seek reimbursement for those sessions only. Can you provide them with just that? or does it need to show the other charges such as room and board if it is all inclusive in the $375 day rate. Sorry if I am confusing you, I am confused myself!
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Not sure why they want you to leave off charges, sounds fishy but I would still again say, show all charges. Insurance will pay their portion. Make sure you not only show the full charges but any payments and/or discounts given, full disclosure is the better way to be safe rather than sorry.   You might be dealing with someone who is hoping insurance company is picking these up as individual sessions but if they are room/board/inpatient charges they probably have a cap on days.. so what they might be wanting is a way to get carrier to pay them as reg outpatient services.. NOPE.. can't do it. don't do it. Give them an itemized bill, collect the portion you know they are responsible for and wash your hands :) JMO

Angie:
That's what it is. The insurance has denied the Residentail Treatment so the patient wants to see if their insurance will reimburse them for the therapy sessions only rather than the daily rate that was denied. So they want an itemized statement of the inpatient individual therapy sessions only but with the inpatient RTC codes (90818).......

PMRNC:
Oh that's def a no no.. IF THE PLAN IS DENYING because they met the inpatient max (may have been with another treatment facility)..  Either way.. that won't be YOUR problem so LONG as your bill reflects the important things.. that it was residential treatment and/or inpatient.. because you do NOT want to mislead the carrier into thinking the patient went in for outpatient therapy.  POS 55 or 56 should be visible on the billing statement. 

Angie:
The plan denied because of clinical; the patient didn't meet their criteria for residential treatment, it went to a Dr to Dr and was denied.
So as long as I put the proper coding the 55 or 56 and the inpatient therapy like Individual 90818 (I have the therapy notes to back it up with) I can provide the patient with that statement of just the therapies  w/o the room and board even though it is all inclusive? It is kind of like unbundling the services; which I don't fully understand........
Some have said you cannot unbundle and some have said you can.....
I don't want to mislead the insurance at all..... The patient is instant that we provide him with this, and he submit it and receive payment from his insurance as he has already paid in full and we are not contracted with the insurance......

PMRNC:
Ok, I have a better understanding.. sorry for being so dense.  Here is what I would do. I would give the patient the SAME bill that you normally give out. When they submit to their insurance the insurance will either pay/deny/unbundled.  Break out the services, use the right POS, CPT codes, DX codes. When the patient gets the EOB and if there is a denial, ask them to bring it in and you can look at it.  Then it's not on you, you are in the free/clear.  BTW, if patient wants something different than what you would normally give out, or they want you to change something, just tell them "No" but tell them you'll be happy to look at their EOB's and you can explain better to them. Tell them your not allowed to change the billing to suit their insurance needs.

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