Part B Insider (Multispecialty) Coding Alert

Published on Fri May 04, 2012 PDF

Question: We dispensed a splint to a patient, but the amount our insurer allows for it is well under the cost to us for that supply. If I bill the insurer I am bound by our contract with them to write off the provider discounted amount in which case our office will lose money. Can I just bypass billing the insurer and offer the patient the option of purchasing without insurance, or is that not allowed since we are contracted with the payer?

Iowa Subscriber

Answer: If you are contracted with the insurer, which it sounds like you are, then your practice agreed to abide by the payer's fee schedule and accept that payment as payment in full. You can't just bill the patient to get more money because you don't like what the insurer would pay. You would be violating your contract (which is fraud), not to mention you'd likely upset your patient (though that's minor compared to fraud).

The way to avoid this is that your practice should review the fee schedules set out in your payer contracts. When your contract is up for renewal, you should consider negotiating on this supply code (and perhaps others) to see if the payer will increase the reimbursement you get.