Wiki Refraction Balance Billing?

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jennawozniak77

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Scenario & question about balance billing & contracts with regard to refractions:
  1. The patient signs a financial agreement to pay $50 at the time of service for refraction
  2. The patient pays the $50 and asks for a detailed bill so they can try to submit it to insurance for reimbursement.
  3. The insurance receives the patient's request and sends electronic payment to the provider for LESS than $50
  4. Can I reimburse the patient what the insurance pays the provider or is this a breach of contract?
  5. I have sent the payment back to the insurance and ask them to reimburse the patient - but the insurance sends the check right back!
Thank you for your help!
Jenna, CPPM
 
Have your checked your contract to see if you're required to submit the claims? I could see if the patient invoked the HiTech Act and didn't want the claim submitted, but if you're in network and the claim is going to be submitted, your contract probably says you have to submit it.

I don't think you can have it both ways here; it's either private pay with no submission or it's submitted.
 
If you are contracted with the insurance you should be billing the insurance; most insurance deny the refraction to patient responsibility as not a covered service. For the insurances that do reimburse you would need to accept the contracted payment and write off. Now if you aren't billing the insurance and they do an audit it could look like you are picking and choosing what to bill which in most cases go against the contract. Now, sometimes when a provider is negotiating their contract they can choose to carve out the refractions in which case then you wouldn't have to bill to the insurance.
 
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