Wiki Self Pay, when you take their insurance

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codernickie

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We are contracted with a patients insurance but they want to self pay for the office visit and have us give them a super bill so they can get reimburse from their insurance company so that the fee they pay can go towards their deductible. Since our self pay fee is based off of medicare fee schedule, it would be cheaper for them to self pay instead of billing it to the insurance which will apply to their deductible. From my understanding since we are contracted with their insurance we have to bill their insurance and not accept self pay. Is this correct?

Please help!!

Thank You
 
I know the patient has the option if they want to be self pay even if they have insurance. It gets really confusing too because if they are self pay and their insurance wants medical records for that date of service you can't send them the information without medical consent. I'm trying to find the in-service I went to showing this. I remember the example during the in-service being a patient having HIV not wanting this on their insurance for the premiums to raise and/or not be able to get insurance in the future.
 
I agree it can be confusing. But The patient wants to pay a lower fee and then submit to her insurance so it can go towards her deductible instead of paying our contracted rate if we bill to her insurance directly. Diagnosis confidential is not the issue for her. I am not sure if this is possible?
 
Fraud

I've worked in Health Insurance for 20 years and then did FWA Investigations for our Health Plans Compliance Department. If the member self-pays, you would need to charge them what you would charge their health insurance. You would still need to submit a claim to the insurance company, reflecting the amount the member paid you. It would then be up to the insurance company to either reimburse the patient the equivalent of your contracted rate with them, or apply it to their deductible. Charging them the lesser amount because they are self pay would be considered fraudulent.

Stacy
 
So if the patient has insurance we are contracted with we would have to charge them the contracted rate and not the self pay fee? What if we are not contracted with their insurance would the self pay fee apply? I thought the self pay fee was based off of Medicare rate and only the contracted rate would apply if we bill the patient insurance? If this is not the case how do create a self pay fee if a patient does not have insurance at all?

Thanks
 
codernickie said:
So if the patient has insurance we are contracted with we would have to charge them the contracted rate and not the self pay fee? What if we are not contracted with their insurance would the self pay fee apply? I thought the self pay fee was based off of Medicare rate and only the contracted rate would apply if we bill the patient insurance? If this is not the case how do create a self pay fee if a patient does not have insurance at all?

Thanks
Click to expand...

You do not have a self pay rate. You have one fee schedule, this is the fee schedule that you communicated to all payers for your services. You cannot decide that insurance gets one fee and self pay gets a different fee. If you had communicated the fee for the service was your self pay rate then the payer would negotiate down to a lower fee. If the patient wants to pay out of pocket then you must charge them from your standard fee schedule. If they want it to go towards the deductible, that will happen when you submit the claim. There are other reasons usually that the patient wants to pay out of pocket.
 
The way it was explained to us from a rep was we are contracted with the carrier and under the obligation to file with that carrier. The patient has signed a contract with that carrier as well so they are obligated to pay their deductibles and copays to the physicans.

You would not be able to give them a self pay rate or that would be fraud.

Karla
 
According to this website >> http://practicemanagementblog.tnaap.org/?p=80

In January 2013, the Department of Health and Human Services issued an update to HIPAA privacy regulations that permit a patient to pay cash.

Patients covered by a health plan may choose to pay their doctor in full for services and choose not to disclose any information to their insurance company ? even if the services are covered by the insurance company.

As for a cash discount - why can't you apply one? You're not having to submit a claim and wait on your money? Anyone that wants to pay on the same date of service should be able to get the discount.

I think we all agree that your patient should not be able to get the discount but turn in your full rate to their insurer. That would be fraud.
 
mitchellde said:
You do not have a self pay rate. You have one fee schedule, this is the fee schedule that you communicated to all payers for your services. You cannot decide that insurance gets one fee and self pay gets a different fee. If you had communicated the fee for the service was your self pay rate then the payer would negotiate down to a lower fee. If the patient wants to pay out of pocket then you must charge them from your standard fee schedule. If they want it to go towards the deductible, that will happen when you submit the claim. There are other reasons usually that the patient wants to pay out of pocket.
Click to expand...

The OIG has made it quite clear that discounts for self pay are appropriate. Multiple fees are not illegal in many states.

http://r.search.yahoo.com/_ylt=AwrT...unts.pdf/RK=0/RS=bdTTEPdeR2.oEdp4UzgjsOJjAhw-

http://www.foley.com/oig-approves-p...am-for-inpatients-and-outpatients-02-15-2008/

http://www.fiercehealthcare.com/story/oig-gives-thumbs-up-to-prompt-pay-discounts/2008-02-11
 
cyndeew said:
According to this website >> http://practicemanagementblog.tnaap.org/?p=80

In January 2013, the Department of Health and Human Services issued an update to HIPAA privacy regulations that permit a patient to pay cash.

Patients covered by a health plan may choose to pay their doctor in full for services and choose not to disclose any information to their insurance company ? even if the services are covered by the insurance company.

As for a cash discount - why can't you apply one? You're not having to submit a claim and wait on your money? Anyone that wants to pay on the same date of service should be able to get the discount.

I think we all agree that your patient should not be able to get the discount but turn in your full rate to their insurer. That would be fraud.
Click to expand...

What's to prevent the patient from coming back 6 months later & asking that we bill their insurance? If their insurance has a 90 day filing limit, it's going to be a provider write off at that point.
 
If we have patients that want the "cash" discount we have them sign a form stating that they are asking us not to bill their insurance. Said form is placed in the record with that day's visit.
 
Its always best if you have one fee schedule, then if you want to apply a self pay "adjustment" or " discount" on a fee or service you can.... that is completely allowed. Doing it this way it would also discourage this patient wanting to do this because the same "fee" amount would be posted....Same price posted (everyone get billed the same price), then post the self pay adj lowering the price for the patient. I agree with the person that said: you can't charge them one price (have different fee schedules) and then they turn a higher price into the insurance company...that is fraud. Dangerous territory on that one.
 
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