General Category > General Questions
out of network provider
best biller:
Hi everybody,
Is there a way for an out of network provider to receive payment from united health care to her office, or only the patient can receive payment?
RichardP:
We have a client who is a non-participating provider for all insurance. Cash only. Patients signs a statement that assigns benefits to the provider. That is noted on the CMS 1500 we send to the insurance company (patient has assigned benefits to provider). Insurance company calculates what they will pay against what we billed and sends that payment to the provider. Provider has patients with United Healthcare where payment is sent to provider, even though provider is non-participating (this is California).
1. If patient paid cash at time of service, and if patient is due a refund after insurance pays, provider's office issues refund to patient (when we tell them what it is).
2. If patient did not pay cash at time of service, we balance bill for the remainder.
The exception is Medicare. Patient cannot assign benefits to the provider, so payment is sent directly to patient.
There are some few other insurances in California that will not send payment directly to the provider, even if the patient authorizes it. You will have to figure out which carriers those are for your own state, since insurance rules and practices vary from state to state.
best biller:
Thanks for the answer
PMRNC:
--- Quote ---We have a client who is a non-participating provider for all insurance. Cash only. Patients signs a statement that assigns benefits to the provider. That is noted on the CMS 1500 we send to the insurance company (patient has assigned benefits to provider). Insurance company calculates what they will pay against what we billed and sends that payment to the provider. Provider has patients with United Healthcare where payment is sent to provider, even though provider is non-participating (this is California).
--- End quote ---
If patient pays cash and provider is non par why do you have patient sign an AOB? I know BCBS won't issue check to NON BCBS par providers as they don't honor assignment for non par. Not sure why UHC wouldn't send benefit to the patient so long as there is no AOB.
RichardP:
If ... provider is non par why do you have patient sign an AOB?
We (billers) don't have the patient sign the AOB. The doctor does. There is a certain logic to why he does it, given that there is an in-house lab involved and he doesn't charge the patients cash for the labs. Mostly, doc just wants to make certain he gets paid for everything he does. If there is any money left over, he refunds it to the patient.
I was just giving best biller real-world evidence that United HealthCare in California will send payment to the doctor. Either Blue Shield of California or BCBS will not send payment to doctor for us in California as well.
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