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#1
07-30-2012, 10:00 AM
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Not billing insurance per patient
There is a debate in our office and I am hoping someone could shed some light for us.
We had a patient come in for a procedure and we hadn't received authorization from the insurance (Blue Shield). Patient said that he didn't want to wait for us to obtain the authorization and would pay out of pocket. Payment was collected from the patient and the procedure was performed. Because we are contracted with the insurance, do we have to bill the insurance or can we just accept what the patient paid? 
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#2
07-30-2012, 11:04 AM
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you need to bill the insurance. I hope you had the patient sign an ABN before receiving the payment and before performing the procedure. If you did then you can keep the payment after the insurance denies the claim. If you didn't have the patient sign an ABN then you can't keep their payment since you are contracted with their insurance. Our contract with commercial payers states that we cannot collect more than the payer says we can collect. So if the payer denies the claim and says $0 patient responsibility then you can't collect anything from the patient without that ABN.
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#3
07-30-2012, 12:40 PM
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Payer-provider contract language seems to prevent the provider from picking and choosing which services go to insurance. I'd suggest having the patient sign a document where he is accepting the financial responsibility for that procedure, just in case the insurance denies it as a provider obligation. And just in case the patient has a memory lapse regarding the situation that day.
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#4
08-01-2012, 05:42 PM
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Payer-provider contracts may preclude the provider from choosing, but it usually says nothing about the patient-member selecting which services he or she shall pay for out of pocket.
I'd add to that ABNs are only applicable to Medicare, so having a Blue Cross patient sign one is like a sieve holding water--it has no bearing. The patient really needs to determine if this is appropriate, though I would support the patient in this instance. As a health care covered member of a health plan, I reserve the right at any time to choose to pay out-of-pocket. The only thing I need to do is state that I have no insurance at that episode of care and I'll receive a bill for it.
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Kevin B. Shields, RHIT, CCS, CPC, CCS-P, CPC-H, CPC-P, CPC-I
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#6
08-04-2012, 09:39 AM
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I agree with Kevin, but if the patient has already communicated that they have insurance then I think this is where the problem lies. SOME Blue Cross plans do have a policy for patient waivers and you should know if this one does or not. Also when you submit the claim there is a field you use to indicate the amount collected from the patient. At any rate it could never hurt to have a statement signed by the patient indicating they decline to wait for authorization and proceeded with the procedure.
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Debra A. Mitchell, MSPH, CPC-H 
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#7
08-05-2012, 11:36 AM
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Debra, that is a great idea! Collect from the patient, away the claim goes and everyone is in compliance and on the up-&-up.
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Kevin B. Shields, RHIT, CCS, CPC, CCS-P, CPC-H, CPC-P, CPC-I
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