Wiki Self Pay Rate

[swaymire]

Can a physician charge a "self pay" rate to uninsured or out of network patients as long as the rate is not less than their Medicare rate? This would be a discount off of the full billed amount, and would be allowed with patients who pay at the time of service. I'm specifically looking for documentation on this from Medicare.

The issue came up relative to Medicare Advantage (Part C) plans. We have patients that want to continue with our providers even though we are out of network with their Medicare HMO. Can we offer these patients a discounted rate (equivalent to the full Medicare rate) or do we have to charge them our full billed amount. We will not be filing these claims to their policy. Thank you!

 

[ehanna]

Can a physician charge a "self pay" rate to uninsured or out of network patients as long as the rate is not less than their Medicare rate? This would be a discount off of the full billed amount, and would be allowed with patients who pay at the time of service. I'm specifically looking for documentation on this from Medicare.

The issue came up relative to Medicare Advantage (Part C) plans. We have patients that want to continue with our providers even though we are out of network with their Medicare HMO. Can we offer these patients a discounted rate (equivalent to the full Medicare rate) or do we have to charge them our full billed amount. We will not be filing these claims to their policy. Thank you!

We charge our uninsured and underinsured a time of service discount of 15% off our normal billed charges. We do not file an insurance claim. We offer this to all who qualify so there is no discrimination. I don't know where to point you for documentation but this is our hospital's outpatient physician practice policy.

I hope this helps

 

[ehanna]

I should follow up by saying we do not give the discount for medications. It is only on the physicians time and effort the discount is given.

 

[mrsjehu]

As long as you are not contracted with their insurance you can offer a discount. We have a 20% prompt pay. We also, offer a hardship rate (they have to fill out a form) for additional discounts. If you are contracted with their insurance (which, you said you were not) but still if you are contracted you can't charge below your contracted rate with that insurance.

 

[wright]

What if a patient has a high deductible. Can an office give the patient a "prompt pay" discount? I have an office asking me if this is ok.
They want to offer patients a discount if the patient pays at the time of service. Example: Patient comes in pays 100.00, at the time of service, the office then files the insurance. The balance after insurance is 125.00 (due to the patient's high deductible)...then the office writes off 25.00. I do not think this is appropriate, however I thought I would ask fellow coders their thoughts.

 

[honeybee]

What if a patient has a high deductible. Can an office give the patient a "prompt pay" discount? I have an office asking me if this is ok.
They want to offer patients a discount if the patient pays at the time of service. Example: Patient comes in pays 100.00, at the time of service, the office then files the insurance. The balance after insurance is 125.00 (due to the patient's high deductible)...then the office writes off 25.00. I do not think this is appropriate, however I thought I would ask fellow coders their thoughts.

I agree with you also. If the patient is using insurance you should collect the amount listed on the EOB as the members responsibility since they have a financial obligation based on the terms of the contract of the insurance plan they are covered by as well as the fact you have an obligation to make an effort to collect since you are a contracted provider with their plan. If a financial hardship applies and you have verified they qualify then adjusting the balance may be appropriate otherwise this should not be something done on a regular basis.