Wiki Not billing insurance per patient


Santa Rosa
Best answers
There is a debate in our office and I am hoping someone could shed some light for us.

We had a patient come in for a procedure and we hadn't received authorization from the insurance (Blue Shield). Patient said that he didn't want to wait for us to obtain the authorization and would pay out of pocket. Payment was collected from the patient and the procedure was performed. Because we are contracted with the insurance, do we have to bill the insurance or can we just accept what the patient paid?
you need to bill the insurance. I hope you had the patient sign an ABN before receiving the payment and before performing the procedure. If you did then you can keep the payment after the insurance denies the claim. If you didn't have the patient sign an ABN then you can't keep their payment since you are contracted with their insurance. Our contract with commercial payers states that we cannot collect more than the payer says we can collect. So if the payer denies the claim and says $0 patient responsibility then you can't collect anything from the patient without that ABN.
Payer-provider contract language seems to prevent the provider from picking and choosing which services go to insurance. I'd suggest having the patient sign a document where he is accepting the financial responsibility for that procedure, just in case the insurance denies it as a provider obligation. And just in case the patient has a memory lapse regarding the situation that day.
Payer-provider contracts may preclude the provider from choosing, but it usually says nothing about the patient-member selecting which services he or she shall pay for out of pocket.

I'd add to that ABNs are only applicable to Medicare, so having a Blue Cross patient sign one is like a sieve holding water--it has no bearing.

The patient really needs to determine if this is appropriate, though I would support the patient in this instance. As a health care covered member of a health plan, I reserve the right at any time to choose to pay out-of-pocket. The only thing I need to do is state that I have no insurance at that episode of care and I'll receive a bill for it.
I agree with Kevin, but if the patient has already communicated that they have insurance then I think this is where the problem lies. SOME Blue Cross plans do have a policy for patient waivers and you should know if this one does or not. Also when you submit the claim there is a field you use to indicate the amount collected from the patient. At any rate it could never hurt to have a statement signed by the patient indicating they decline to wait for authorization and proceeded with the procedure.
I have a patient that told us she was self pay, month later she calls us stating she didn't know she had insurance at the time, now the insurance is wanting us to submit a claim to them for service that have already been paid for. by law do i have to submit this claim ? Insurance is stating once they pay us we are to refund the patient their money.
I believe that under HIPAA and/or HITECH, patients actually may choose whether or not a claim can be filed to insurance.

"According to Section 13405 of Subtitle D of the HITECH Act (42 USC 17935), a health care provider must honor a patient request to restrict disclosure of protected health information to a health plan for purposes other than carrying out treatment (namely, payment or health care operations) if the patient pays the health care provider out of pocket in full."

We have been advised that only if the patient fails to pay for services, can we then bill insurance against their wishes. I would appreciate any additional feedback that others have on this statute.
Hi, 100% agree with previous post. Actually it is stated or should be in your Notice of Privacy Practices. Which should be available at patients request if they ask. Hope this helps. Thanks