Wiki Payment posting for cash patients

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Blackhorse

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If you are out of network with Anthem, you charge a patient $150 cash for a certain service that Anthem is not covering. This patient later file a claim with Anthem and the payment is applied to the patient's deductible which is $87.00. You office received the EOB for the service, do you need to post this payment? Since your office has never sent out the claim to Anthem, financial history shows that $150 charge has been paid by the patient, how do you post the $87 PR? Can patient file the claim after they have already paid cash to the office? I guess this is the question about how to correctly bill OON claims.
 
My first question would be, would the payer truly not cover it, or would it be covered at an out of network rate? If the patient submitted a claim to the payer, and they processed it to deductible, it means it was "covered". If it wasn't they would not have processed it to deductible. The patient can file there own claim if the provider doesn't.
I would want to check the member's policy again before I did anything with the account. It depends on if they have out of network benefits at all or not. From what you are describing it sounds like they possibly have a PPO with in and out benefits. You would also want to check the EOB against your statement or superbill to see what the patient submitted to insurance. It just sounds like it needs more looking into.
However, even if they put $87 to the patient's out of network deductible, if your provider is not in-network with a contract, you can still (usually) balance bill for the difference.
 
amyjph said:
My first question would be, would the payer truly not cover it, or would it be covered at an out of network rate? If the patient submitted a claim to the payer, and they processed it to deductible, it means it was "covered". If it wasn't they would not have processed it to deductible. The patient can file there own claim if the provider doesn't.
I would want to check the member's policy again before I did anything with the account. It depends on if they have out of network benefits at all or not. From what you are describing it sounds like they possibly have a PPO with in and out benefits. You would also want to check the EOB against your statement or superbill to see what the patient submitted to insurance. It just sounds like it needs more looking into.
However, even if they put $87 to the patient's out of network deductible, if your provider is not in-network with a contract, you can still (usually) balance bill for the difference.
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Agree. I know there can sometimes be a distinction with BCBS between being participating or non-participating. You can be a non-network provider, but still be participating.

Most often "participating" means that payments for out of network services will come to you directly instead of being issued to the patient, and in return you agree to submit claims and typically not balance bill.

If you're both non-network and non-participating, then typically you'd be able to charge the full $150 for the service. If you're non-network but participating, you may want to check the terms of your participation.

The patient likely wanted to submit the claim to at least receive whatever credit they could towards their out of network deductible.
 
MD thinks this is a non-covered service but according to the EOB, the payment was processed based on the patient's OON benefit which is a covered service. But I'm still very confused how the billing was processed. My previous experience tells me that we need to submit claims to the carrier for PPO patient who have OON benefit, if the carrier send the payment to the patient, we need to bill the patient. However the MD thinks that it doesn't make any difference to charge patient's cash or bill patient later because they have to pay us anyways.

I know some offices have cash patients sign "select to pay cash" agreement, these patients will pay cash to the office and cannot file any claims to their insurance. If an office takes cash from patients and have never submit any claims to the insurance, are you supposed to only post the payment from the patient?

Our office sends superbills to insurance once patients pay cash to us. If the patient doesn't file the claim to the insurance, will insurance process the claim for the patient by simply receiving the superbill from us?

I guess that I'm confused what is the correct way to process OON claims. The medical office submit the claims to insurance and later bill patients, or charge patient's cash and have patients file their own claims, or either way is ok and correct.
 
The patient may have an FSA or HSA that they want reimbursement from for the service they paid cash for; however, the only way that can happen is if the claim is first processed by the patient's health plan. Also, they may have a secondary insurance policy or even an indemnity plan that pays X amount for office visits/hospital stays/diagnostics services (these policies are like what Afflack sells). So, there could be a number of reasons the patient submitted the claim to the insurance company.

As to your question about how to correctly process OON claims, it is going to depend on the patient, I think. Some will want you to file the claim on their behalf and then once the insurance processes the claim, they would then need to pay you whatever their outstanding account balance is. Some will pay up front and submit the claims themselves. There is no hard and fast rule about who has to submit the claim when the provider is truly out-of-network, and the patient is going to be self-pay.

Most insurance companies require that for member submitted claims that all the information necessary to process the claim is included with their claim submission, which will include the provider's NPI # and when the insurance company processes the claim they issue you (the OON provider) an EOB/remit, although many insurance companies don't send these to OON providers, even if the OON provider submitted the claim on behalf of the patient.
 
Hi CBLENNIE, thank you so much for your information and I've learnt a lot from you. Some office have patients sign "selecting to pay cash" agreement, on this agreement, it says that cash patients can not file the claim for the service that they choose to pay cash. Do you know the rationale behind this agreement?
 
Blackhorse said:
Hi CBLENNIE, thank you so much for your information and I've learnt a lot from you. Some office have patients sign "selecting to pay cash" agreement, on this agreement, it says that cash patients can not file the claim for the service that they choose to pay cash. Do you know the rationale behind this agreement?
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Happy Hump Day Blackhorse! In my 20+ years in this industry I have only ever worked on the payer side, and I have no idea why a provider would require a patient to sign an agreement not to file the claim with insurance if they are self-pay.

I have one theory that is if the provider is in-network with the patient's insurance plan most of provider contracts with the insurance companies obligate them to file the claims to the insurance company. The provider may not want to file the claim because there may be network discounts applied to the services billed and the provider doesn't want to have to deal with reconciling the overpayment on the patient's account or just doesn't want to get paid less than they were originally paid by the patient.

Maybe someone in the community that is on the provider side of things and has a good understanding about the revenue management can explain this policy for both of us because I'm curious about it too. :unsure:
 
CBLENNIE said:
Happy Hump Day Blackhorse! In my 20+ years in this industry I have only ever worked on the payer side, and I have no idea why a provider would require a patient to sign an agreement not to file the claim with insurance if they are self-pay.

I have one theory that is if the provider is in-network with the patient's insurance plan most of provider contracts with the insurance companies obligate them to file the claims to the insurance company. The provider may not want to file the claim because there may be network discounts applied to the services billed and the provider doesn't want to have to deal with reconciling the overpayment on the patient's account or just doesn't want to get paid less than they were originally paid by the patient.

Maybe someone in the community that is on the provider side of things and has a good understanding about the revenue management can explain this policy for both of us because I'm curious about it too. :unsure:
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Hi CBLENNIE, thanks a lot for providing more information from the payer's aspect. I think I understand better now when billing for INN and OON claims. Many providers including dentists use INN tax ID to submit claims directly to carriers; and use OON tax ID to charge patients' cash. They are so smart!
 
You are more than welcome for the information. I try to help those posting on the forum understand things from the insurance side of things.
 
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