General Category > General Questions

client wants to pay direct to psychologist

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PMRNC:
NO. Regardless of whether the provider is Par or not, they still must adhere to the cost sharing provisions of the patients policy. For example if the doctor NORMALLY charges $100 a visit, but they want to discount, they must show the discount but it will make NO difference to the carrier, they will pay based on the plans policy.   For example, if the provider wants to accept only $80.00 that's fine, but he will still need to bill to the insurance company and either bill the $80 or show the $100 charge with the $20 discount. Either way, the carrier is only going to cover THEIR portion of their U&C (non par) or allowable (par).  It is considered fraud to waive out of pocket copay's and coinsurance/deductibles. Whether a provider is par or not is of no exception.

rdmoore2003:
that is correct -post meant that it was correct that if provider is contracted that they can only charge the patient the insurance rate.  maybe i should have explained better.   if provider is contracted with insurance they must: if they charge $100 for visit but contract says pt has deductible of $300.00-the patient must pay their deductible before the insurance pays.  visit is 100.00, pt has 300.00 ded, contract allows 42.00 for the 100.00 charge, you can only charge the 42.00 to the pt.  that would leave 258.00 to deductible....

sorry I didnt explain better.

kwardbilling:
Thanks, i do understand about adhering to the cost sharing provisions set forth by insurance policy, my question is more about if the patient can pay provider direct and submit for reimbursement herself. The provider hasn't suggested discounting. So example provider charges $100 for session, patient pays provider, patient submits to insurance company, insurance pays patient allowable amount. Does that make sense and sound correct? Again provider is not contracted with CIGNA. Thanks again for all of your responses.

PMRNC:

--- Quote ---Thanks, i do understand about adhering to the cost sharing provisions set forth by insurance policy, my question is more about if the patient can pay provider direct and submit for reimbursement herself. The provider hasn't suggested discounting. So example provider charges $100 for session, patient pays provider, patient submits to insurance company, insurance pays patient allowable amount. Does that make sense and sound correct? Again provider is not contracted with CIGNA. Thanks again for all of your responses.
--- End quote ---

Yes patient can pay in full. Just make sure the itemized bill reflects the FULL charge and full payment. I've seen doctors "collect" the discounted amount, give patient an itemized bill to submit and the bill includes full charge w/out mention of the discount. That is fraud. The bills have to match all the way around. If the provider discounts the charge it needs to be shown as such.

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