Question Global billing

julesh

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I need some help, I have a commercial in network HMO provider, charging a patient their copay for pre-op and post-op care (removal of stitches). As I know it, both are included in the 90 day global period. They were paid for the surgery and did not bill the insurance for the pre/post care just charged the copay. I know this is not allowed with CMS, is this the case with commercial coverage? I see it as double dipping, payment for pre/post was included in the primary surgical code which they were paid for. Am I on the wrong track, if not where can I find something in writing stating such?
 

thomas7331

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Generally speaking, the rules for when a provider is or is not allowed to collect a copay are driven by the provider's contract with the insurance payer, and with that payer's policies, which a provider agrees to abide by when they sign the contract. To get a definitive answer, your best bet would be to discuss this with the particular payer.

Some providers do collect a copay or an estimated amount due at every visit just as an office policy, and there is nothing wrong with doing this. But the payments collected must be applied to some charge, and if there is no change posted, or if the bill is paid in full, then the credit is returned to the patient or applied to the next visit.

But to retain a copay when no charge has been made, or when the claim is processed by insurance and the determination is made that no copay is due, then the provider cannot just keep the money - that would be fraudulent accounting, like pocketing money from the cash register, so to speak. If the patient has concerns, they always have a right to request an itemization of their account, which would show the payments that have been made and the charges to which they have been applied, and these should either balance to zero, or show an amount due or a credit. This is just standard accounting practices.
 

thomas7331

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Copays can only be assessed if there is a charge to apply the payment to, otherwise what are they charging a copay for? The determination as to whether or not a copay is owed would be made by the insurance company when they process the claim, not by the provider.

You don't need to find anything in writing for this - just look at the patient's account as this is an accounting issue. If they are collecting a copay but not charging or billing anything for the visit, then that should create a credit balance on the patient's account. The provider cannot retain credit balances - these would need to be refunded to the patient or else applied to another visit or charge. If there is no credit balance and no charge for the visit, then the where is the money being applied?
 

julesh

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I agree! They did not bill the insurance, I can not say if a charge was placed on the account and placed under patient responsibility. When the patient questioned the fee they stated it was their policy. If that is the case wouldn't that still be incorrect or does commercial insurance allow this? I have tried to find information on this topic and can't. Is this just a standard we as coders expect and know due to CMS and our CPT knowledge? Is this office choosing not to practice this standard or is there a formal rule they must follow?
 

CatchTheWind

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No, commercial insurance does not allow this! If a visit is within a global period, you can't bill insurance or the patient (unless the visit is for an unrelated problem). They are cheating their patients.
 

sjtrew

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I need some help, I have a commercial in network HMO provider, charging a patient their copay for pre-op and post-op care (removal of stitches). As I know it, both are included in the 90 day global period. They were paid for the surgery and did not bill the insurance for the pre/post care just charged the copay. I know this is not allowed with CMS, is this the case with commercial coverage? I see it as double dipping, payment for pre/post was included in the primary surgical code which they were paid for. Am I on the wrong track, if not where can I find something in writing stating such?
Copays are not collectible for pre and post op care - these services are included in the global service and not separately billable, therefore no copay should be collected.
 

dkissel

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There should be an insurance commissioner in your state where you can go to research the rules/regulations. In Michigan it's the DIFS (Department of Insurance and Financial Services.) If you go to the website, you can view every PDF of every rule in place, not only for health insurance but for all types of insurances for our state. Hopefully you have a resource like this.
 

CodingKing

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What Thomas said. If there is no RAS listing a copay there is no copay due from the patient. Copay/coinsurance is tried the the allowed amount. No allowed means no collect. The same if the allowed was less than copay, patient would owe the total allowed and not the full copay.

You could always make an anonymous complaint to insurance companies FWA or compliance department
 
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