Wiki Billing patient for non-coverd services??

[l1ttle_0ne]

We have a case where we billed Humana for some pathology services (we do the TC portion of the pathology). The pathology codes were not on our fee schedule for Humana. So they are denying a couple of services for patients. Stating that it's provider write off. Our boss is telling us to transfer the balance to the patient. However we did not have the patient sign any non-covered services forms. This is the first time I've run into this. It's my understanding that if the insurance denies it as a non-covered service you have to have had the patient sign a waiver before services were rendered to bill them. Can anyone clarify for me??

 

[CatchTheWind]

If a service is something that is never covered (cosmetic procedures, eye exams, that kind of thing), you can bill the patient with no problem, as this is something that simply falls out of the scope of their insurance coverage.

If a service is denied because it does not meet medical necessity guidelines (ie: it is sometimes covered, but not for this particular diagnosis or the documentation doesn't support medical necessity), for Medicare patients you can only bill the patient if they signed an ABN. No exceptions! For commercial payers, you may have to get guidance from the payer as to whether they will allow you to bill the patient if the patient didn't sign an ABN-type form.

In your case, it sounds like you have performed a service which would have been covered if performed in-network, but you are not in-network for it (even though you are in network for other services). In this case, theoretically, you could check with Humana to see if they will allow you to bill the patient. HOWEVER, I strongly believe that it would be unethical to do so. Here's why: When you scheduled the patient you misrepresented yourselves to the patient (inadvertently, of course) by leading him to believe that you were providing in-network services, then you performed services for which you are out of network.

 

[l1ttle_0ne]

If a service is something that is never covered (cosmetic procedures, eye exams, that kind of thing), you can bill the patient with no problem, as this is something that simply falls out of the scope of their insurance coverage.

If a service is denied because it does not meet medical necessity guidelines, for Medicare patients you can only bill the patient if they signed an ABN. No exceptions! For commercial payers, you may have to get guidance from the payer as to whether they will allow you to bill the patient if the patient didn't sign an ABN-type form.

In your case, it sounds like you have performed a service which would have been covered if performed in-network, but you are not in-network for it (even though you are in network for other services). In this case, theoretically, you could check with Humana to see if they will allow you to bill the patient. HOWEVER, I strongly believe that it would be unethical to do so. Here's why: When you scheduled the patient you misrepresented yourselves to the patient (inadvertently, of course) by leading him to believe that you were providing in-network services, then you performed services for which you are out of network.

Thank you! I completely agree with you. I don't believe the patient should be billed for this service, but our boss doesn't seem to agree...

 

[LisaHoman]

if the Humana coverages is not a Medicare or state Medicaid managed care program, and you do not have a contract (In network provider agreement) then you can bill the patient. If a contract exists, refer to that agreement.