Out-of-Network provider

rbapat

Networker
Messages
41
Best answers
0
I have a question about a provider who is out-of -network and wants to see patients as self-pay. Is there a waiver that patients need to sign so that the provider doesn't have to bill their insurance and the patient pays the full amount out-of-pocket. Also, what if the provider is in-network but patient chooses to not bill their insurance and wants to be self-pay?
 

thomas7331

True Blue
Messages
2,657
Best answers
7
It the patient is covered by a government-sponsored plan, then there are legal requirements that must be followed by the providers regardless of whether or not they are in the network.

For commercial, non-government plans, however, if the provider is out-of-network, then that implies that the provider does not have a contract with the payer and therefore there is no obligation to that plan - the provider may require the patient to pay and they may elect to not bill the insurance. No waiver should be required, but it may be a good idea so that there is a clear understanding between the patient and the provider.

If the provider is in-network with the commercial plan, but the patient opts to not use their insurance, that is the patient's right and they may choose to be self-pay and not have the service billed to their plan. Again, in this situation it may be a good idea to have this in writing to prevent any misunderstandings.
 

SharonCollachi

True Blue
Messages
683
Location
Clovis, CA
Best answers
3
If the provider is in-network with the commercial plan, but the patient opts to not use their insurance, that is the patient's right and they may choose to be self-pay and not have the service billed to their plan. Again, in this situation it may be a good idea to have this in writing to prevent any misunderstandings.
First, in this situation, I would check your contract, as it may be prohibited there, even if indirectly, such as: "contracted provider agrees to bill the health plan..."

Second, I would think long and hard about this. The patient could come back later and tell the health plan that they were coerced into signing an agreement, and now they want it billed to the health plan. Or they could simply try to bill it themselves later, in which case the health plan will contact you to see why you're not billing them for in-network services.

We refuse to go down that road of hassle any longer. We just say no. If you've given us your insurance, we're billing it. If you filled out the forms as self-pay, that's our ace-in-the-hole, so to speak, for any problems in the future. Our documents have a statement the patient has to sign verifying the truthfulness of the information they gave us.
 

sab001

Networker
Messages
46
Location
Pasadena/LaPorte Texas Chapter
Best answers
0
Section 13405(a) of the Hitech Act speaks to the individual's ability to request that PHI not be disclosed when paid out of pocket in full. The Federal Registry on page 5626 discusses this further by stating, "We stated that we interpret section 13405(a) as giving the individual a right to determine for which health care items or services the individual wishes to pay out of pocket and restrict.." Also in the same Federal Registry, "With respect to Medicare, it is our understanding that when a physician or supplier furnishes a service that is covered by Medicare, then it is subject to the mandatory claim submission provisions of section 1848(g)(4) of the Social Security Act (the Act), which requires that if a physician or supplier charges or attempts to charge a beneficiary any remuneration for a service that is covered by Medicare, then the physician or supplier must submit a claim to Medicare. However, there is an exception to this rule where a beneficiary (or the beneficiary’s legal representative) refuses, of his/her own free will, to authorize the submission of a bill to Medicare. In such cases, a Medicare provider is not required to submit a claim to Medicare for the covered service and may accept an out of pocket payment for the service from the beneficiary." There is much more in the registry than what I've quoted.

Professionally, I would have a form available for the patient to sign attesting that they desire for insurance to NOT be billed for the service rendered. This further protects you if the patient goes off and seeks compensation from insurance by filing the claim directly with the insurance.
 

rbapat

Networker
Messages
41
Best answers
0
Section 13405(a) of the Hitech Act speaks to the individual's ability to request that PHI not be disclosed when paid out of pocket in full. The Federal Registry on page 5626 discusses this further by stating, "We stated that we interpret section 13405(a) as giving the individual a right to determine for which health care items or services the individual wishes to pay out of pocket and restrict.." Also in the same Federal Registry, "With respect to Medicare, it is our understanding that when a physician or supplier furnishes a service that is covered by Medicare, then it is subject to the mandatory claim submission provisions of section 1848(g)(4) of the Social Security Act (the Act), which requires that if a physician or supplier charges or attempts to charge a beneficiary any remuneration for a service that is covered by Medicare, then the physician or supplier must submit a claim to Medicare. However, there is an exception to this rule where a beneficiary (or the beneficiary’s legal representative) refuses, of his/her own free will, to authorize the submission of a bill to Medicare. In such cases, a Medicare provider is not required to submit a claim to Medicare for the covered service and may accept an out of pocket payment for the service from the beneficiary." There is much more in the registry than what I've quoted.

Professionally, I would have a form available for the patient to sign attesting that they desire for insurance to NOT be billed for the service rendered. This further protects you if the patient goes off and seeks compensation from insurance by filing the claim directly with the insurance.
This is very helpful, Thanks!
 

rbapat

Networker
Messages
41
Best answers
0
Section 13405(a) of the Hitech Act speaks to the individual's ability to request that PHI not be disclosed when paid out of pocket in full. The Federal Registry on page 5626 discusses this further by stating, "We stated that we interpret section 13405(a) as giving the individual a right to determine for which health care items or services the individual wishes to pay out of pocket and restrict.." Also in the same Federal Registry, "With respect to Medicare, it is our understanding that when a physician or supplier furnishes a service that is covered by Medicare, then it is subject to the mandatory claim submission provisions of section 1848(g)(4) of the Social Security Act (the Act), which requires that if a physician or supplier charges or attempts to charge a beneficiary any remuneration for a service that is covered by Medicare, then the physician or supplier must submit a claim to Medicare. However, there is an exception to this rule where a beneficiary (or the beneficiary’s legal representative) refuses, of his/her own free will, to authorize the submission of a bill to Medicare. In such cases, a Medicare provider is not required to submit a claim to Medicare for the covered service and may accept an out of pocket payment for the service from the beneficiary." There is much more in the registry than what I've quoted.

Professionally, I would have a form available for the patient to sign attesting that they desire for insurance to NOT be billed for the service rendered. This further protects you if the patient goes off and seeks compensation from insurance by filing the claim directly with the insurance.
First, in this situation, I would check your contract, as it may be prohibited there, even if indirectly, such as: "contracted provider agrees to bill the health plan..."

Second, I would think long and hard about this. The patient could come back later and tell the health plan that they were coerced into signing an agreement, and now they want it billed to the health plan. Or they could simply try to bill it themselves later, in which case the health plan will contact you to see why you're not billing them for in-network services.

We refuse to go down that road of hassle any longer. We just say no. If you've given us your insurance, we're billing it. If you filled out the forms as self-pay, that's our ace-in-the-hole, so to speak, for any problems in the future. Our documents have a statement the patient has to sign verifying the truthfulness of the information they gave us.
It the patient is covered by a government-sponsored plan, then there are legal requirements that must be followed by the providers regardless of whether or not they are in the network.

For commercial, non-government plans, however, if the provider is out-of-network, then that implies that the provider does not have a contract with the payer and therefore there is no obligation to that plan - the provider may require the patient to pay and they may elect to not bill the insurance. No waiver should be required, but it may be a good idea so that there is a clear understanding between the patient and the provider.

If the provider is in-network with the commercial plan, but the patient opts to not use their insurance, that is the patient's right and they may choose to be self-pay and not have the service billed to their plan. Again, in this situation it may be a good idea to have this in writing to prevent any misunderstandings.
Thank you!
 
Top