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Non participating providers with commercial carriers

  1. #1
    Question Non participating providers with commercial carriers
    Medical Coding Books
    I was just thrown for a loop today and wanted to see if I have been living in the dark or is the organization I am with have a chance to collect a bunch of money they have been writing off.

    When you are non participating with a commercial carrier you are not required to write off anything, is this correct? My understanding was you can submit a claim to insurance for the patient but you still get paid your full amount be it from a combo of the insurance and patient paying or just the patient if insurance never comes thru for whatever reason.

    I just found out today that if you are non par with Aetna they have a 90 day filing limit. If we aren't getting are claims in during this time frame (ie the insurance shows no record of the claim doesn't mean we didn't send it), they (our billing department) is writing them off. This blew me away. Am I wrong? I was told that we have to follow the insurance bylaws and regulations. I have never heard of this before. If this is the case does someone have the link for them? I can't find anything. I am in Michigan.

    I don't normally have any involvement in the back end collection process where I work now so I had no idea this was going on.


    Laura, CPC, CEMC

  2. Default
    Hi Laura,

    Yes, I agree that if you don't have a contract with a payer, you can expect full reimbursement (either from the plan, the patient or both).

    In the situation you just described, I would say, if you told the patient you would file the claims and then they were denied for timely filing, I would write off the charge. I'm not 100% sure what the insurance bylaws are with regards to this but I would say if you took filing the claim out of the patient's hands, then you can't turn around and bill them for an error on your part. Of course, if filed on time, then I would appeal with proof of timely filing and fight for that money from the insurance company.

    If this appears to be a big problem, you could tell your out-of-net patients they will need to submit their own claims (which, I know, is a headache if its anything more than an office visit) but then the onus is on the patient to get the claim in on time. Then if denied for timely filing, you could still bill the patient the full balance.

    This is just my opinion though.

    Lisi, CPC

  3. #3
    If you are Non-Par, then why is 'your' timely filing limit 90 days? Most carriers I have dealt with only has that stipulation on par providers.

    If it was your fault, then write off all but what would have been the patient liability. However, did the patient present accuate information upon the visit? My PCP's office requires a copy of or presentation of the card each time I go in otherwise they ask me to pay it and sign a form that says I will be responsible whether or not my insurance pays or doesn't pay. You may need to consult with a lawyer to get the correct language to use on the form to protect your practice and ensure you are not breaking any laws.

    food for thought

  4. #4
    Milwaukee WI
    Default Non Par Procedures / Policy
    You need to have a policy in place that will guide how this is handled. The office staff AND the patient should both fully understand this policy at the time of the patient visit.

    OPTION 1 - you will bill patient and expect payment in full from patient. (Could be PIF at time of visit, or down payment with billing for balance.) Patient is free to file claim with his/her insurance and insurance can pay the patient directly.

    OPTION 2 - you can bill the patient's insurance, but have the appropriate disclosure information signed by patient accepting full responsibility for the bill if not paid by insurance, or not paid in full by insurance (so if your bill is $1,000 and insurance pays $500 you can bill the remaining $500 to patient).

    I would definitely get this policy straightened out and ensure that your billing office is appropriately handling denials and not just writing everything off.

    There is simply NO excuse for the claim not to go in within 90 days and even for there to be follow-up within that time frame. I would suggest a guideline of claim submission within 10 days of date of service; with follow-up for open invoices 30 days post claim submission.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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