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Billing Insurance two different rates

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barb2512:
Depending- If a client is paying for visits which will be charged against their deductible the provider is setting the fee per appt at $80 so that only $80 will be charged as the client's responsibility because that is all the client can afford. Then when the client meets her deductible the counselor charges her regular fee of $150 for a 90834. The insurance will reprice the claim and the client will owe her copay.

This doesn't look kosher to me. Any thoughts?

Thank you,
Barbara

PMRNC:

--- Quote ---Depending- If a client is paying for visits which will be charged against their deductible the provider is setting the fee per appt at $80 so that only $80 will be charged as the client's responsibility because that is all the client can afford. Then when the client meets her deductible the counselor charges her regular fee of $150 for a 90834. The insurance will reprice the claim and the client will owe her copay.

This doesn't look kosher to me. Any thoughts?
--- End quote ---

You had me until you said: 
--- Quote ---The insurance will reprice the claim and the client will owe her copay.
--- End quote ---

To answer this simply.. THE provider best be charging the rate they are collecting. If they are Charging $80, the insurance should be billed $80 showing patient payment if they paid, if they try and bill the regular rate of $150 when doctor is only taking $80 that's absolutely wrong. The insurance company has to be billed the same amount as the patient is billed. The out of pocket is the out of pocket, the patient has to pay the full out of pocket (coinsurance) no matter what.
You can also check with the plan and see if they have deductible carryover months for Oct/Nov/Dec   many plans still have those.

I am not sure what you meant by insurance will reprice..they won't go back ..but the patient is still going to be responsible for the coinsurance/copay/deductible up to either the fee schedule (if par) or up to U&C if non par.

barb2512:
I am sorry if I wasn't clear.

Client's paying $80 an appt and insurance is getting billed $80 an appt until client meets deductible.

After deductible is met client is paying copay and counselor is billing insurance $125 an appt.

b.

PMRNC:

--- Quote ---I am sorry if I wasn't clear.

Client's paying $80 an appt and insurance is getting billed $80 an appt until client meets deductible.

After deductible is met client is paying copay and counselor is billing insurance $125 an appt.
--- End quote ---

This seems OK..But I would tend to really think about this.. and unless you have an office policy that makes this UNIFORM across the board, you could run into trouble later... Despite what people believe.. non govt payors DO indeed scrutinize providers and WILL flag certain things. A drastic change in fees COULD be a red flag.    Your office financial policy that all patients receive should be uniform and this way all patients are treated equally, you take risk of a carrier red flagging you for fee schedule billing changes.. that COULD be problem.. it's NOT illegal as long as you are billing the same fee to insurance carrier as you are the patient..but it COULD be a problem if the provider is making all kinds of different concessions. If you have another patient who has NO deductible but on same plan, the provider could be red flagged..   It's a crap shoot.

barb2512:
Thank you!! I appreciate all the feedback. Have been going back and forth on it. Uniformity is definitely the way to go on it.

Barbara

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