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jhendrix08

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Hello....

Looking for some advice on how to handle a situation. We have a patient that has been seeing us as private pay; she stated she was uninsured. We found out today that she did indeed have insurance (one that we do take) and that she never notified us...because of her history, we think it's likely that she didn't tell us because she thought we didn't take the plan and she wanted to continue seeing our physician.

My question is, for the three visits where the patient paid cash we are now outside of the filing timeframe for billing her insurance so we would not be able to get reimbursed. Do we still have to reimburse her? If not, do we have her sign something stating that we were made aware that she has insurance and that she will not be reimbursed for those past visits?

Thanks for the help. I just want to be sure this doesn't come back to bite us.
 
In my experience, many payer contracts or policies contain a clause that if a patient did not provide their coverage information or the practice had no reasonably way of knowing it, then providers are within their rights to hold a patient responsible for the payment. Unless your contract states otherwise, I don't believe you are required to reimburse the patient. For purposes of customer service, you might consider filing the claims on her behalf, making her aware in advance that you expect denials due to her failure to provide this information, and advise her that in this case she will need to attempt an appeal to her insurance company on her own. I believe most payers would stand by you on this and not require you to take a loss on services that were provided in good faith.
 
Patient disclosure of insurance

I think it is important to ask the patient if she wants insurance billed as she has the right to pay out of pocket and not have the information regarding these visits disclosed to the payer. If the patient chooses not to use insurance, be sure the records for these visits are noted to not be disclosed to the payer. Hope that is helpful. Cindy

jhendrix08 said:
Hello....

Looking for some advice on how to handle a situation. We have a patient that has been seeing us as private pay; she stated she was uninsured. We found out today that she did indeed have insurance (one that we do take) and that she never notified us...because of her history, we think it's likely that she didn't tell us because she thought we didn't take the plan and she wanted to continue seeing our physician.

My question is, for the three visits where the patient paid cash we are now outside of the filing timeframe for billing her insurance so we would not be able to get reimbursed. Do we still have to reimburse her? If not, do we have her sign something stating that we were made aware that she has insurance and that she will not be reimbursed for those past visits?

Thanks for the help. I just want to be sure this doesn't come back to bite us.
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Pt didn't disclose insurance

Have you asked the patient directly if she wants you to bill her insurance? Why would you try and solve that without speaking to the patient directly? There may be a reason the patient does not want the insurance to be billed.

working at a well known medical center we have many patients who choose not to use their insurance policy for some of their visits; this is well in their rights to do so. They are then charged the full rate (as is the insurance) and it is paid according to whatever agreement was put in place ( i say it this way because there are many ways a self-pay patient is set up for reimbursement. a self-pay discount, pre-approved payment arragement etc).

when a patient is seen they are usually asked to sign something that would make them responsible financially as well as giving the providers permission to treat them. This document as well as payment at the time of service makes the patient solely responsible so that the rendering provider is "not left holding unpaid visits" .

a practice/clinic/medical center should NEVER bill an insurance policy if the patient specifically asked for their insurance not to be billed. If a patient has sepecifially asked to be a self-pay patient then let them be a self-pay patient. There is nothing in the contract between their insurance company and a provider that indicates once needs to "report" a visit etc.

in fact should the patient 'find out' that a bill was sent to the insurance you will be opening up a can of issues that the practice may not want to take on ... since you are not sure WHY a patient is opt'ng to be a self pay one should just leave the issue alone as an angry patient is not fun. patients have been known to write bad reviewes on many many social media plateforms if their specific requests were not followed and sending a claim to an insurance company without the patient's permission; well you might as well have given out their private information thus going against HIPAA (opinion) .

there are many links that can be googled that would support what i have written and in fact one can call the insurance and inquire but remember insurances are out to find 'pre-existing conditions; diseases not disclosed (perhaps) etc' so one has be VERY CAREFUL WHAT IS SAID even to the insurance company if the patient has not given permission to do so.


Twenty-Five (25) years in the health care industry with twenty-two (22) years as a revenue manager.
 
I appreciate you all taking the time to provide some feedback for me. I haven't discussed any of this with the patient yet because we realized she was insured after she had already left the office. I will be sure to discuss with her regarding sending claims to her insurance; this is not something I was planning on doing without her consent.

I actually did not realize that an insured patient could see their provider and opt out of their insurance being billed and pay for the visits. We haven't run into this scenario before. Does the same rule apply if the patient has an insurance that we are not contracted with? Say, for instance, a new patient wants to make an appt and has a Medicaid plan or an HMO plan that we aren't contracted with. Can the patient opt out of using their insurance and see us as private pay? I was always under the assumption that this is not good practice.

Thanks again for the advice...much appreciated.
 
Pt didn't disclose insurance , need advice

A patient can always opt out of using their insurance however you must ALWAYS have a patient sign a consent form (aside from the permission to treat).. it's usually called something like "financial waiver" if you do not have one you should have one created I say this because it's always good to have 'extra' protection for your practice 'in case' the patient comes back and says "oh by the way i have XX HMO and i want you to bill them" ... which we all know cannot be done after so many days and/or depending on what type of treatment the patient had done.

the financial waiver pretty much says what the consent to treat form says with an extra paragragh that indicates the patient is aware they are a self pay and she/he is responsible for charges even if the patient requests to bill an insurance company at a later date.

There is more to it than that but that's the gist of it. Like I mentioned before I dealt with this a lot and patients will come back and say I need a refund because you needed to have billed my insurance (that she/he was not aware they had at the time of service) fortunately for us we had the waiver signed so we billed but it did not exonerate the patient from being responsible for services and money was never refunded.
 
Thank you Rebecca! Your advice is great and I appreciate you taking the time to offer advice. I will definitely bring this up with the office manager and physician.
 
state laws for pt refunds

I have been told that each state has laws on statue of limitations on patient refunds does anyone know where I would find those? Currently looking for Michigan
 
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