billing for bundled services

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Mesa, AZ
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If you are not contracted with an insurance can you bill codes that you know are mutually exclusive? I have been billing for 15 years and I think I know the answer, but I have been told that if you are not contracted and the insurance pays everything else we can legally bill the patient? Any thoughts?
Thanks
Sarah:)
 

kbarron

True Blue
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Ossipee, NH
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bundled services

Does the EOB say you can balance bill the pt? I tend to use the same rules for everyone. We use modifiers if they have the ins or not.
 

Erica1217

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Chicopee, MA
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I follow CPT and CCI guidelines regardless of payor.

I don't think it's fair or ethical to bill the patient for services you shouldn't be reimbursed for.

If it's bundled, it's bundled for a reason.. meaning you are getting a payment for a service that includes payment for another service.

To bill the patient would be almost like billing the patient twice for the same service.

:) Erica
 

kevbshields

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Louisville, KY
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Erica's on track . . .

Erica has nailed this one: ethics. My leanings are similar to hers. If AMA considers two services bundled, M.E. or otherwise inherent to one another, there is little justification for intentionally breaking those stated rules. I believe it could be argued that knowingly ignoring or bypassing those rules could constitute abuse or fraud.

Keep in mind that laws like Anti-Kickback Statute cover related areas (waiving co-pays); although I am not a compliance expert, I know enough to advise against any practices of this sort. The rules of billing should probably be applied universally unless contracts dictate otherwise.

Good luck. This would an interesting question for the Coding Edge "Coding Compass" column . . .
 

Susan

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Chandler, AZ
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I like Erica's Response

Great response Erica! When we have a cash patient come into the office for surgery we only bill what is allowed to be billed. Charging a patient in our office for a service that is bundled is forbidden. I feel bad enough for the uninsured patients paying the fees that they do have to pay. I could not sleep well if we even considered billing them for bundled services.

We do have patients that come into our office using their out of network benefits and we stick to what the EOB states after processing allowing them the benefit of the reduction by their insurance carrier.

Have a great day!
 
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San Diego
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Hi,

I also agree with Erica....especially, since my current insurance coverage for myself and my family is very limited. I get to see what it feels like to be the "patient" and would not feel good about having to pay for services that I as a "coder" know should not be billed together, etc.

I think that "fair is fair" really applies in this case. Appropriate coding, combinations of codes, use of modifiers, etc. should not change based on payor to spike reimbursement (with the exception of certain code sets based on payor).

Just my two cents...
 
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