Wiki Non Covered Charges

[cheryldicken18@gmail.com]

General billing question: A patient presents to the office (Podiatry) and has 2 procedures performed. One procedure we know is a non covered charge by the insurance. Are we allowed to only bill the 1 procedure to the insurance, and have patient sign non covered charge waiver and collect payment for the other procedure?

 

[CBLENNIE]

• Are you asking about commercial insurance companies or are you asking for all payers including Medicare and Medicaid?
• Also, are you contracted (in-network) with which ever payers that these patients are covered by?

Your answer to these questions does impact my response so without this additional information I can't give you an answer that addresses your question accurately.

 

[cheryldicken18@gmail.com]

• Are you asking about commercial insurance companies or are you asking for all payers including Medicare and Medicaid?
• Also, are you contracted (in-network) with which ever payers that these patients are covered by?

Your answer to these questions does impact my response so without this additional information I can't give you an answer that addresses your question accurately.

Commercial and Medicaid, and yes we are contracted.
Medicare I know has ABN's.
Thank You!

 

[CBLENNIE]

I can't speak what is allowed by Medicaid as I work for a commercial insurance company. As for commercial insurance companies they are all going to have their own rules on this subject. For my company if the provides a service that is specifically listed as non-covered in the patient's plan/policy/contract then you are not obligated to bill us for the non-covered service.

However, if the item "may or may not be covered" by their plan then you should submit it to the insurance company, and we do have our own commercial version of an ABN so you could have the patient sign it and bill it with the GA modifier to indicate you have the documentation on file that they agreed to pay if it is denied as non-covered, which would then make the charge patient responsibility on their EOB.

From your original post it seems like you are advising the patient up front the service is non-covered and collecting payment, or advising them of the cost of the service, is that correct?

If you are not doing so under the No Surprises Act there is a provision that requires providers to give uninsured patients, those who lack coverage for a particular item or service or those who are not using their insurance for services a good faith estimate of expected charges. I won't get into the weeds in trying to explain all of the nuances of this provision of the No Surprises Act unless you have questions because you are not providing the patient with the cost of the non-covered service up front or are just curious. You can also read up on the subject on CMS' Regulation and Guidance site under the No Surprises Act there is a link to information on Good Faith Estimates for Uninsured (or self-pay) individuals.