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Handle Non-Covered Services for Non-Medicare Patients

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  • In Billing
  • August 23, 2011
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By Delly Parham, CPC
When a patient elects to receive a service deemed medically unnecessary or non-covered by his or her insurer, the patient is financially responsible for the charges. These services may be included in your participating agreement with the insurance carriers or they may be obtained from insurances. When your provider determines that a service is medically unnecessary, always advise your patients and consider these tactics to help preserve revenue:

  • Implement a financial policy for non-covered services that includes:
    • Non-covered services are to be paid at the time they are rendered.
    • The patient must sign a notice of non-covered service indicating his or her acceptance of financial responsibility.
    • Inform the patient that no coded receipt of the visit will be provided.
    • If the patient pays cash, a cash receipt will be provided (cash receipts can be obtained from a local office supply store).
    • No claim will be sent to the patient’s insurance carrier at any time, now or in the future, unless the patient wants a denial for a flex plan or some specific coverage. For these patients, verify the coverage.
  • Do not allow your patients to dictate how and when your practice bills insurances for non-covered and/or medically unnecessary services. It is the provider’s responsibility to make coverage determinations.
  • Do not misrepresent non-covered or medically unnecessary services as covered services to “help the patient get the service reimbursed by insurance.” This might be fraudulent under the False Claims Act.

Warning: Providing patients with coded receipts (e.g., V50.9 and A9270) would allow the patient to submit the bill to the insurance carrier. The service could be considered by the carrier and may be covered for a low dollar amount. If you are contracted with the patient’s insurance carrier and the patient gets a non-covered or medically unnecessary service covered and paid, your practice is obligated to refund the difference between the amount you collected at the time of service, and the amount the carrier paid, OR you should refund the insurance carrier with a letter stating that the service should not be covered because the provider has deemed the service “not medically necessary.”
Remember to check payer contracts for hold harmless language. And remember it can be noncompliant to provide services to a patient and then refuse to bill with hopes of retaining the patient’s payment.

CPB : Online Medical Billing Course

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