Wiki Billing an insurance after the patient presented as self pay

[cmorris109]

I work for a pathology company and many times we receive our patient information without insurance info so the patient is sent a bill as if self pay. However there are also times that the patient calls to say they have insurance that their doctor didn't provide us and ask if we can file it with their insurance. If the patient bill is 75% of Medicare but our charge prices to the insurance company are double Medicare, is it legal for us to send a claim to the insurance that is higher priced than the original self pay patient statement?

 

[thomas7331]

I do think that it is a potential compliance issue to have two fee schedules as you've described here. While many practices will offer a self-pay/prompt pay discounts and may offer reduced rates based on financial hardship, it's unusual to simply have a different set of fees for a patient without insurance. This could indeed be considered fraudulent, because per the False Claims Act, the amount billed on a claim must represent the amount that the practice accepts as payment in full for that service. If you are maintaining a fee schedule on your books that is for a lower amount but you are not representing that fee to the payers on your claim, you could be out of compliance. A safer practice would be to have a single fee schedule. Then if a patient is self-pay or shows that they have a financial hardship, you may offer them an incentive to pay their bill in full by discounting the bill. This avoids the potential problem of being accused of misrepresenting your charges on claims. Ultimately though, this process is something that your company's compliance officer and management needs to review and revise.

 

[sab001]

Good answer, @thomas7331 .

@cmorris109 - I would also like to add that there are services out there that perform insurance discovery in situations such as this. The specimen is received with incorrect or missing insurance information. The third-party vendor would use their resources to discover if a patient has insurance that was not reported. I recommend reaching out to the billing software company to see if they have partnerships with companies that perform insurance discoveries or demographic discoveries.

 

[SharonCollachi]

This (False Claims Act) is why I tell people to NEVER have more than one fee schedule.

And, as you can see, if you ever have to go back and bill an insurance company, your fee won't change.