to bill or not bill

nkorab

Networker
Messages
52
Best answers
0
If a patient wants to pay cash for a visit and/or procedure, but he has insurance that we are
contracted with- Can we do this?
or are we obligated to bill the insurance because of our contract? He has a medicaid plan.

Don't know if its a legal law or what?
Any advice is appreciated.

Nancy
 

cgaston

Expert
Messages
494
Location
Clarence, NY
Best answers
0
You don't have to bill the insurance carrier for a service but you do need to create a charge for it. You can bill it as a self pay and then apply the patient's payment to it.
 

duboses

New
Messages
6
Best answers
0
Medicare has a mandatory claim submission rule

Medicaid is a joint federal and state program. It, therefore, follows many of the Medicare rules.

Whenever you provide a 'covered' service to a Medicare / Medicaid beneficiary (patient), federal law requires that you follow the rules of Medicare in almost every instance. Which means filing a claim with Medicare / Medicaid.

In your post you said you are "contracted" with the insurance. If this means that you are a "participating provider" with Medicare / Medicaid, then you should follow what is shown in #1 below. Otherwise consider one of the other two options.

1. You are a participating provider withMedicare.

If Medicare covers the service provided to the beneficiary, you cannot accept self-payment from the beneficiary (beyond the standard deductible and 20% coinsurance for the service). You must bill Medicare directly for covered services provided to beneficiaries.

2. You are a non-participating providerwith Medicare.

You can accept self-payment in full from the beneficiary at the time of service, but you still must send claims to Medicare for any covered services. Medicare will then send any applicable reimbursement directly to the patient.

3. You have no relationship with Medicare.

In this situation, you cannot provide covered services to a Medicare beneficiary on a private-pay basis. Due to the mandatory claims submission rule, if you provide a covered service, you will have to send a claim for that service to Medicare. However, because you have no relationship with Medicare, you have no way of submitting claims.​
 
Last edited:
Messages
373
Best answers
0
Patients right to restrict billing to insurance

If a patient wants to pay cash for a visit and/or procedure, but he has insurance that we are
contracted with- Can we do this?
or are we obligated to bill the insurance because of our contract? He has a medicaid plan.

Don't know if its a legal law or what?
Any advice is appreciated.

Nancy

The HITECH act included a provision as follows.
(vi) A covered entity must agree to the request of an individual to restrict disclosure of protected health information about the individual to a health plan if:

(A) The disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law; and

(B) The protected health information pertains solely to a health care item or service for which the individual, or person other than the health plan on behalf of the individual, has paid the covered entity in full.

Health plan in this act is defined as:
Health plan means an individual or group plan that provides, or pays the cost of, medical care (as defined in section 2791(a)(2) of the PHS Act, 42 U.S.C. 300gg-91(a)(2)).

(1) Health plan includes the following, singly or in combination:

(i) A group health plan, as defined in this section.

(ii) A health insurance issuer, as defined in this section.

(iii) An HMO, as defined in this section.

(iv) Part A or Part B of the Medicare program under title XVIII of the Act.

(v) The Medicaid program under title XIX of the Act, 42 U.S.C. 1396, et seq....

Based on this, I would say that you must abide by the patient's wish to not have their insurance billed and carefully document this information. You may wish to obtain legal advice regarding how to accommodate this from your organization's health care legal adviser. State medical societies and professional liability companies are also good sources of information on topics such as this.

Hope that helps.
Cindy
 

cgaston

Expert
Messages
494
Location
Clarence, NY
Best answers
0
Per the Federal Register, Vol. 78, No. 17, the HIPAA rules state:

“With respect to Medicare, it is our understanding that when a physician or supplier furnishes a service that is covered by Medicare, then it is subject to the mandatory claim submission provisions of section 1848(g)(4) of the Social Security Act (the Act), which requires that if a physician or supplier charges or attempts to charge a beneficiary any remuneration for a service that is covered by Medicare, then the physician or supplier must submit a claim to Medicare.

However, there is an exception to this rule where a beneficiary (or the beneficiary’s legal representative) refuses, of his/her own free will, to authorize the submission of a bill to Medicare. In such cases, a Medicare provider is not required to submit a claim to Medicare for the covered service and may accept an out of pocket payment for the service from the beneficiary. The limits on what the provider may collect from the beneficiary continue to apply to charges for the covered service, notwithstanding the absence of a claim to Medicare. See the Medicare Benefit Policy Manual, Internet only Manual pub. 100–2, ch.15, sect. 40, available at http://www.cms.gov/manuals/Downloads/bp102c15.pdf.

Thus, if a Medicare beneficiary requests a restriction on the disclosure of protected health information to Medicare for a covered service and pays out of pocket for the service (i.e., refuses to authorize the submission of a bill to Medicare for the service), the provider must restrict the disclosure of protected health information regarding the service to Medicare in accordance with § 164.522(a)(1)(vi).”
 
Top