Wiki Asking patient to file their own claim

[jwitt18#]

Our office pays $78.00 for a pessary and when we bill the insurance most of them pay around $22.00. Therefore we are not at least breaking even to provide this service. Legally can we choose to not bill the patient's insurance (except Medicare) and ask the patient to pay $78.00 and file their own claim to their insurance? If so what type of document could we use? Thanks in advance for any help.

 

[njsenff]

I believe it is legal to ask the patient to file their own claim. But you could not discriminate so you would have to ask this of every patient and every service. One thing you have to ask yourself is, does your company has a contract with the insurance company.
If you are purchasing the pessary for $78 and the insurance is only paying $22. I would suggest that your purchasing department needs to shop around to receive a better discount on your medical supplies.

 

[dclark7]

If you are contracted with the insurance company and the service you are providing is a covered service you cannot ask the patient to pay for the service, nor can you require them to submit the claim themselves. If it's a non-covered service you can request payment at the time of service, but you must inform them prior to providing the service that it's non-covered. If you are not contracted then you can require payment at the time of service and have the patient submit their own claim. Most of the time when a nonpar practice submits claims it's as a courtesy to the patient.

If you are not even breaking even on this service then not only is shopping around for a better price an option, but your docs may want to consider not providing the service. I know many docs don't want to stop providing services, but if you're consistently losing money you'll eventually have to make the decision anyway.