No Referral? Have Patient Acknowledge Financial Responsibility
Question: I have a primary care pediatric practice, but will be offering after hours care (5-9 p.m. weekdays, 9-5 p.m. weekends) beginning next month. If we offer services to patients not in our practice (i.e., do not have one of our doctors listed as primary care provider), we are concerned that claims will be denied. Is there a different way to code or bill for patients who seek our after hours care services who are not in our primary care practice?
Answer: “I recommend that the provider collect up front if he or she isn’t the patient’s primary care provider, and that the office offer to submit claims for reimbursement for the patient,” advises Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CPC-I, CHCC, CENTC.
The practice financial policy should be clear that the patient is receiving services during off hours, and that services provided by anyone other than the patient’s primary care doctor may be denied as a result of insurance company rules. The provider cannot accept responsibility for such denials, or for denials resulting from non-participation in the patient’s insurance.
“By signing the financial policy, the patient understands that he or she is responsible for all charges incurred for services received,” Cobuzzi says.
Additionally, if the practice structures itself as an urgent care clinic during off hours, you may wish to report services offered during these hours using place of service code 20 Location, distinct from a hospital emergency room, an office, or a clinic, whose purpose is to diagnose and treat illness or injury for unscheduled, ambulatory patients seeking immediate medical attention.
Finally, Cobuzzi notes, “There are legal and administrative considerations when you call a practice ‘Urgent Care,’ particularly in some states.” To learn more, she recommends reading “Top Four Legal Issues to Consider When Opening an Urgent Care Center.”
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