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Not billing to an insurance carrier

  1. #1
    Location
    Rochester NY
    Posts
    77
    Default Not billing to an insurance carrier
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    Hello,

    Does anyone know if there are any legal or ethical ramifications for not billing a service to a patient's insurance carrier?

    The patient is requesting that we don't bill her services, she fears discrimination by the payer. We've told her that it is illegal for them to do that - but, to no avail.

    Currently it is blood work that she does not want billed. Personally I don't think that she realizes there is more to blood work than the blood draw fee. The lab is going to look for payment for processing her blood requisition.

    All I can find on google searches is about professional courtesy. She is not asking for any fee waivers so none of what I am reading seems to apply.

    I'm thinking there could be future issues with the not billing of services. My thought is, if there is any issue with her blood - it could snowball quickly. I don't want our office in a sticky non-compliant spot because the patient is paranoid.

    Any thoughts?

    Thanks
    A. Judd

    2013 President, Flower City Professional Coders
    2012 Vice President, Flower City Coders local Chapter
    2011 Member Development Officer, local chapter

    "You cannot truly listen to anyone and do anything else at the same time." M. Scott Peck

  2. #2
    Location
    Tacoma, WA
    Posts
    1,087
    Default
    Quote Originally Posted by ajudd View Post
    Hello,

    Does anyone know if there are any legal or ethical ramifications for not billing a service to a patient's insurance carrier?

    The patient is requesting that we don't bill her services, she fears discrimination by the payer. We've told her that it is illegal for them to do that - but, to no avail.

    Currently it is blood work that she does not want billed. Personally I don't think that she realizes there is more to blood work than the blood draw fee. The lab is going to look for payment for processing her blood requisition.

    All I can find on google searches is about professional courtesy. She is not asking for any fee waivers so none of what I am reading seems to apply.

    I'm thinking there could be future issues with the not billing of services. My thought is, if there is any issue with her blood - it could snowball quickly. I don't want our office in a sticky non-compliant spot because the patient is paranoid.

    Any thoughts?

    Thanks
    You are not required to bill an insurance carrier if the patient requests they not be billed, unless she is on a state Medicaid plan. Medicaid is granted based on need, so if someone is able to pay out of pocket for their medical care, then they may be denied future Medicaid coverage.

    I would get a quote from the lab for the cost of the tests planned so she is aware of what she will owe once the labs have been processed and have her sign a waiver stating she has insurance coverage, but is requesting no billing be sent to the insurer.

    Be sure to include a note in her record that you counseled her regarding the privacy and discrimination issues. You can always check with your practice attorney or malpractice company for additional advice.
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

  3. Default
    A point to be made here is that having insurance is not a requirement. She is insured at will. From a practice standpoint would you deny her services if she was uninsured but able to pay? You will not run into any issues with not billing her insurance. As a matter of fact, you will be doing the insurance a favor by them not having to pay. If there is a complication with her bloodwork that could lead to further tests down the road all the insurance MAY need is the lab values from the bloodwork which your office will have anyhow.
    If you are worried about her paying then have her pay for the services up front. On a cover your butt basis - I would have her sign something that does state that she wishes this exam not be sent to her carrier.
    As far as her paranoid behavior please don't dismiss the idea that her insurance may discriminate against her. If the condition that she is having the bloodwork done in search of falls into the "list" the insurance can raise her premiums, deduct, co-pays, limit her services, etc. The Affordable Care Act doesn't have to be implemented until 2014 for adults - thankfully it is in play for kids! If she is looking at a change in her insurance she may be worried that she will be discriminated against because she simply had the test done and is in fear that she will have coverage issues until 2014.
    I am also going to take this a little further because of a bad experience a few years ago when I was working at the hospital emergency room prior to becoming a coder. There was a 45year old patient presenting to the ER with stomach cramping and high fever. She made the same request... please don't bill the insurance for any of this - they will discriminate against me and we have to renew our policy soon..... She paid the visit - minus a standard discount for prompt payment - on her credit card and all was well. We had to run x-rays on her and failed to notify the reading radiologist that she was a self pay and they billed the insurance that they had on file for her. About a month later EMS brought the same woman in accompanied by law enforcement after she was involved in a domestic. When the woman came to and saw where she was she flipped and started blaming all of us for what happened to her. As it turns out the patient didn't want the insurance billed because she didn't want her husband to see the EOB and question the services which is exactly what happened; it is what landed her back in the ER - All over one bill! She is the reason I left working an ER and went into coding. Long story short - the patient may not be telling you everything and you have no way of knowing this until it is too late. If she has the means to pay and is willing to do so upfront - go with it. If the insurance questions it down the road - you will have the results and that is all that they need anyhow.

  4. #4
    Location
    Columbia, MO
    Posts
    12,570
    Default
    You may want to check your contract on this, a patient may be deliberatly trying to hide a condition from her insurance to avoid higher rates or exclusions. I would tread lightly until you know where you stand with that carrier.

    Debra A. Mitchell, MSPH, CPC-H

  5. #5
    Location
    Louisville, KY
    Posts
    1,101
    Default
    Patients absolutely carry the right the determine if they or the insurance company are the payer of a particular service. I'll concur with other posters that patients reserve this right, just as the insurance company reserves the right to call a particular claim "non-covered" and make that patient responsibility.

    As for the patient withholding information from the insurance company, that is a matter of contract that exists between the patient and the payer--and likely does not involve the provider. I am not saying they don't exist, but I have never seen a provision in a provider-payer contract that stipulates all services must be billed to the insurance carrier (minus Medicaid, which is mentioned in full detail above).

    I'm sorry, but this is a non-issue. If I, as a patient, determine that I want to pay out of pocket for the services from a particular provider or all my care, that is my choice and financial decision. Here's another great example: I once encountered a patient who wanted private pay for all services within the 4th quarter of the year. When someone finally brought this up to the patient, in a nice, neutral way, the patient indicated she did this to positively impact her taxes--spending greater than 7% of your annual income on health care costs apparently is or was a substantial deduction.

    It's not much of your business, so long as you respect the patient's wishes.

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