Question Billing A Covered Procedure As Self Pay

k4lilly

Contributor
Messages
14
Best answers
0
Hi,

My office is looking to start doing lidocaine infusions in the office. The set up fee is very costly, and the reimbursement for the 96365 and 96366 CPT codes averages around $140 for the 4 hour process. The manager is wondering if he can make this procedure a self pay only procedure and charge $500.

I feel that this is not allowed as these patients are insured and the procedure is otherwise covered by their policies (I have checked, it is covered) so I do not think that we are allowed to bill them as self pay and not utilize their insurance.

Does anyone have any info on this that I could present to demonstrate my point to them...........I assume that I am correct LOL.........please do let me know if I am wrong!

Thank you very much!
Kelly
 
Messages
160
Location
Clovis, CA
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0
You're setting yourself up for trouble. Most contracts say you have to bill the insurance. Now if you're not contracted, you can charge whatever you want because you are not bound by the contract rates (unless it is a government program like Medicare, Tricare, etc.).

If you are contracted, and you do it cash pay, the patient can still bill it themselves to insurance, or complain to insurance, and then you'll be stuck refunding money to the patients. Totally not worth it.
 

sab001

Networker
Messages
44
Location
Pasadena/LaPorte Texas Chapter
Best answers
0
Hi,

My office is looking to start doing lidocaine infusions in the office. The set up fee is very costly, and the reimbursement for the 96365 and 96366 CPT codes averages around $140 for the 4 hour process. The manager is wondering if he can make this procedure a self pay only procedure and charge $500.

I feel that this is not allowed as these patients are insured and the procedure is otherwise covered by their policies (I have checked, it is covered) so I do not think that we are allowed to bill them as self pay and not utilize their insurance.

Does anyone have any info on this that I could present to demonstrate my point to them...........I assume that I am correct LOL.........please do let me know if I am wrong!

Thank you very much!
Kelly
Kelly,

The answer to your question is NO and YES.

No. Your provider cannot make this procedure a self-pay only procedure for all patients.

Yes. A patient (only the patient) may opt to avoid insurance billing for the test (even if the service is routinely covered.) The HITECH Act, Section 13405 of Subtitle D of the HITECH Act (42 USC 17935)], allows a patient to restrict the provider from filing a claim to the payor. See page 39 of the Act. https://www.hhs.gov/sites/default/files/ocr/privacy/hipaa/understanding/coveredentities/hitechact.pdf --- Basically, the patient is saying, protect my privacy and do not share this PHI with my insurance company. In case the payor comes back and asks why you didn't bill the payor for a covered service, you should obtain a written request from the patient where the patient instructs you to NOT bill the payor.

Why would a patient do this? Consider a young lady who goes in for pregnancy testing and doesn't want the policy holder to know that the testing took place. The young lady can instruct the provider (preferably in writing) to accept a cash payment in lieu of billing the insurance.
 
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