Billing > Billing
Does a medical procedure claim have to be bundled with a office visit claim ?
PMRNC:
--- Quote ---Question: In some instances, doctors will bill primary but not secondary. Does anyone know of situations where the doctor's office will give patient a copy of the fee slip containing codes the doctor's office will use to bill primary, plus a blank CMS 1500 Form for the patient to fill out and attach to the appropriate paperwork when the patient bills the secondary?
--- End quote ---
Regardless of insurance, provider's have to make available a full itemized bill. I don't know if they will give you blank HCFA's (I'm assuming with their signature stamp?) I sure wouldn't let my clients do that. that's just asking for fraud inquiry. Patients are ok to either send in a copy of the original superbill with the EOB from primary OR if their carrier requires their own billing form the provider will usually complete it, sign it and give it to them to file or file it themselves.
Either way.. what this person wanted to do in "creating" a bill is absolutely incorrect.
RichardP:
It just occured to me that I don't know if there is some standardized way for patients to submit their information to their insurance carrier. None of our client's patients bill for themselves, so I have no experience with that. Hence my question about whether patients who bill for themselves fill out a CMS 1500 Form.
A different, but related issue: there is no actual doctor's signature in whatever field holds the Box 31 info when billing is done electronically. And the paper CMS 1500 forms we send only have the doctor's name typed in Box 31; no actual signature. Your responses in this topic make me think that some doctors actually sign their name in Box 31?? Otherwise, why the concern about how the patient billing for themselves fills out Box 31. I would think they would just write the name of their physician in that box.
PMRNC:
I'm only going to speak as to what I think is right/wrong, plus I worked at insurance companies processing claims. first, this person wanted to "CREATE" the billing with a question on what charges to put there and what not, codes to apply or not.. etc. that's absolutely fraud, intentional or not. Second.. every office should have policies and procedures and included would be "secondary/tertiary claims". IF a provider does NOT routinely file secondary claims there should be a procedure for this in their P&P. My clients do NOT give out CMS1500 forms UNLESS the patient gives them one from their carrier in which they will complete for them. If the carrier does not require that form of billing from the insured they will accept a superbill (most will). Let's say a provider decides to give them the CMS 1500 to bill.. one would HOPE that it's full and complete with all procedures and charges and what was paid, if not the provider has no business giving out blank and signed CMS1500 forms. If they do.. that's not exactly fraud on their part but I can tell you that the carrier will look twice at it. Whomever files that claim is the one at risk. This poster was pretty clear they were asking WHAT CPT charges they should include and mentioned several times a "manual" billing. As a biller and as a former claims examiner I see red flags all over the place. Many people don't realize this but it's easier to catch insured/patients claim filing fraud than providers. While they may show some Mercy with 'ignorance" it still puts a red flag in the carriers file. IF a provider's policy is NOT to file secondary than a procedure must be spelled out throughout the office that they will give an itemized superbill for billing. It's not that difficult. There really is NO REASON a provider should provide a CMS1500 form OUTSIDE of the carriers requirements.
RichardP:
Thanks for the response. I know you can print blank CMS 1500 Forms off of the Internet. Wasn't sure if that is what patients who bill the insurance themselves would use. You said that most carriers will accept a superbill. That answered my question.
Merry:
I would never ever have a patient sent in their claim on a CMS 1500 form. For Medicare, in the very rare instance that a patient would need to submit a bill (and I honestly cannot think of a reason) they would use a CMS-1490S which you download from the Internet. I do not know if you can use this for commercial insurance.
A medical provider is required to give you the diagnosis and procedure codes if you ask. If you need to submit your own bill, they can even do it on their letterhead as long as their NPI and the necessary information is included.
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