Wiki Making patients self pay vs billing ins

[sbrabham]

Some staff in our office have contradicting opinions...

Background: Our office doesn't accept new patients with a "xyz" insurance. But we are in network with the insurance and file for our current patients only.

If a patient was originally a self pay patient, but now has "xyz" insurance, would it be wrong/illegal for us to tell the patient we do not accept their new insurance and they will remain a self pay patient? Is it the provider's obligation to the insurance to bill to the insurance? We couldn't give them the self-pay discount could we?

 

[mitchellde]

Some staff in our office have contradicting opinions...

Background: Our office doesn't accept new patients with a "xyz" insurance. But we are in network with the insurance and file for our current patients only.

If a patient was originally a self pay patient, but now has "xyz" insurance, would it be wrong/illegal for us to tell the patient we do not accept their new insurance and they will remain a self pay patient? Is it the provider's obligation to the insurance to bill to the insurance? We couldn't give them the self-pay discount could we?

You cannot refuse to bill if you are contracted with the insurance and you should not have a self pay discount at all.

 

[CodingKing]

I don't know if its the same with all payers but the one I work for you cant close your panel to an established patient switching insurance carriers (same if you are obtaining insurance. An established patient is an established patient regardless of who is paying. Also many payers have a rule where you cannot close panel for one payer only. if you are open panel for one payer you are open for all payers.

 

[mattra]

This ultimately depends on your contract with the insurance company, but in most cases your contract will say you can't refuse to bill the insurance for this patient. You risk losing your contract altogether by doing so.

It also seems like you would probably be alienating this patient, and they are sure to spread the word that you gave them a hard time. To me, it seems like it's not worth it to create a PR problem over billing the insurance company for one more patient.