Wiki Billing a Pt instead of their Ins


Port Charlotte, FL
Best answers
I'm looking for some information to support my claim that you can not bill a patient for a procedure because you don't like what their insurance reimburses you, even though we are a participating provider. Example:
Our Dr. (ob/gyn) performs a circumcision but bills the patient because Medicaid reimburses so poorly, even though we have billed Medicaid for all of the mother's ob care. I tried to explain that since we par we can't pick and choose what services we want to bill for and that if we want to get paid more then we need to negotiate better when our contract comes up for renewal. They want this in writing. Please help!
Since Medicaid is governed by CMS this would not be a good idea! Check the CMS website for specific info to back you up if it is required by your doc, but you are absolutely correct - the ins must be billed and contract payment/adjustments accepted.
If you participate with the patient's insurance company, you must bill the carrier and not the patient (unless the service is specifically not covered by the patient's plan). If you see a Medicare patient and you do not participate with Medicare, you can request payment from the patient at the time of service, but you must file the claim with Medicare. I'm not totally sure with Medicaid, but I agree with Lisa---since it's governed by CMS, you probably shouldn't bill those patients. Medicare has a different fee schedule for non-participating providers. If you do not participate with a certain insurance carrier, you are under no obligation to bill that carrier or accept payment as "payment in full". A lot of larger practices bill those carriers as a courtesy to the patient.
oh I know we can't negotiate w/ them....they barely pay anything let alone getting them to agree to pay more would be impossible. silly me.

I'll check to make sure it is a covered procedure first but I still think we have to bill the insurance to the denial first and then they can tell us what to bill the patient, correct?
Billing Patient

If you are contracted with an insurance company, Medicare or Medicaid, you are obligated under that contract to accept their reimbursement and only bill the patient what they indicate on the EOB is the patient's responsibility - i.e. deductible, coinsurance, and copayments. You can also bill the patient if it is a procedure that is specifically excluded from payment if it is a commercial insurance. If the patient is a Medicare patient, you must get an ABN prior to treatment, indicating that the patient has been informed that the procedure will likely not be covered by Medicare and why, and that they agree to take full financial responsibility for the procedure if it is denied by Medicare. A similar form can be used for Medicaid patients in SOME states, but the regulations vary from state to state, so it is best to check what your state's regulations are to avoid potential legal actions. I have personally run into this particular issue numerous times, and that is the most up to date information I have received from CMS and several states Medicaid offices.

Shelly Kubacki, MPA, CPC

We have done several circumcision, but Medicaid does not pay for this procedure in the State that we are in. Pt is made aware of this at the time of there OB visit and that if they have a boy they will be billed for the circumcision and we have forms that they sign stating their benefits.
It is not a covered service here in Florida. Must be paid for by the patient if they want it done.[/QUOTE]

I'm specifically referring to Medicaid and it is listed as a payable service.
Medicaid contract governs

If it's a covered service per Medicaid in your state, and you have signed a contract to accept Medicaid payment, then you must do so. Bill it to Medicaid, then see what your EOB says. You may not be able to bill the patient at all, but this may be one of those services where you can bill a portion to the patient.

You said your doctor wants it "in writing." The contract the practice signed with Medicaid should address this.

F Tessa Bartels, CPC
Update; now what

I actually found out yesterday that Medicaid only covers this when it's considered Medically necessary. So does this free me up to be able to bill the patient now? What about the fee, can I charge them what I want or does it have to be the same as what Medicaid pays when med necessary?