Wiki Medical Practice Fee Schedule Questions!

[rbassett]

Two separate questions:
1.) Can you bill self pay patients at just the Medicare allowable rate?
2.) Can a patient request to be self pay instead of us billing their insurance? Are we allowed to comply or refuse to comply with their request?

This is an ongoing discussion at my clinic currently so I need references as to why or why not these things aren't allowed. We are an ophthalmology clinic.
Thanks!

 

[ellzeycoding]

1. Yes. You may charge self-pay patients your Medicare allowable rates.

2. A patient can restrict the use of their medical information (PHI) to their own health plans. See the 2013 HIPAA Regulations (see 45 CFR 164.522(a)(vi)), and in the preamble to these regulations (see 78 Fed. Register 5566, 5626-5630).

a. Get the request in writing (have a form prepared) that the patient is requesting a restriction on disclosing their PHI to their health plan.
b. The patient must pay in-full at the time of service in order to restrict disclosure of their PHI to their insurance
c. The patient may not restrict the disclosure for treatment purposes, only payment purposes. Meaning if you need to share the patients information with another provider or referring provider, you can still do so.
d. Be careful. Some commercial contracts may have verbiage that they REQUIRE you to bill them for all services for all patients they cover. But the HIPAA provision would trump any verbiage in your contracts.

 

[cgaston]

Your charge for a service should not differ between insurance companies and self patients so I was taught that you bill out your entire fee and then adjust off the difference between your charge and the Medicare rate as a "special consideration" (or whatever your company wants to call it).