Posts Tagged ‘self-pay’

What Exactly Did The Omnibus Rule Allowing Regarding Patient Restriction Of Disclosure To Insurance Carriers

In Uncategorized on September 4, 2013 at 6:31 pm

Remember that pesky contractual provision in your provider participation agreements that obligates you to submit all claims for patient services to the insureds’ carrier(s) for processing?  Even if the patient didn’t want that claim to be filed?  Well, Congress has spoken, and the Omnibus Rule contains a provision that, as federal legislation, trumps those contracutal obligations. 

The Omnibus Rule now allows patients to pay a medical bill in full at the time of service and request that the provider NOT file a claim to the patient’s insurance company.  Again, this is a complete contradiction of previous rules, which demanded that patients and providers comply with their contractual obligations to file all claims to the carrier providing insurance coverage for the patient.  So, providers, take note:  if a patient pays his/her bill in fill at the time of service, and requests that your office not submit the claim to his/her insurance carrier, any submission constitutes a violation of HIPAA and the Omnibus Rule going forward!

This disclosure restriction relates only to services for which patient has paid in full.  So, if the patient pays by credit card, and that card is denied or if the patient pays by check and the check bounces, then the provider must to attempt again to obtain payment in full from the patient (absent sending to collections).  If the provider makes that attempt and is unable to obtain payment, then the he/she may finally submit the claim to the patient’s insurance company despite patient’s initial desire not to disclose the services.  Essentially, while the provider does need to try to comply with the patient’s desire for privacy, he/she does not need to forego compensation.

M.E.D.I.C., Inc.  would suggest that when the patient pays in full and asserts his/her right to restrict disclosure of the services, providers have those patients complete and sign a form to be maintained on file that identifies :

  1. whether this is a one-time claim restriction or permanent restriction on disclosure;
  2. that the restriction would need to be for the entire claim, not portions of the visit, for attempting to select only certain elements of a claim to restrict may be difficult due to “bundling” of procedures…  It is much more administratively efficient if the restriction is is an all-or-nothing proposition;
  3. the consequences of payment retraction (the denied credit card, the bounced check, etc…) – in other words, explain to the patient that in the event of these non-payments, the practice will make one attempt (only one attempt because of the short timely filing for some carriers) to collect payment.  Absent payment in full, the practice will then file the claim(s) to the patient’s insurance carrier – despite his/her previous desire to restrict disclosure;
  4. that a perhaps unforeseen consequence of this restriction is that the patient’s payment will not be applied to his/her deductible

As always, please contact M.E.D.I.C., Inc. should you have any questions related to this, or any other, medical billing/revenue cycle management matter.


Can Your Practice Discount Self-Pay Patients?

In Uncategorized on August 22, 2013 at 6:47 pm

Recently, an issue arose dealing with a practice’s ability to offer a discount exclusively to self-pay patients.  Following the old educational philosophy that if one person has the question then the odds are that others do as well, I am addressing that matter here.  

Generally speaking, there is no prohibition against a physician discounting a fee for a self-paying patient (that is, a patient who pays out-of-pocket and is not covered by a health plan, including Medicare or Medicaid).  A practice can always offer purely self-pay patients a discount, and many do, otherwise the self-pay patient is stuck being charged the full fee schedule amount, while insured patients benefit from contractual write-offs which adjust the practice’s charge down to the  contractual allowable. 

Where a practice can run into issues is when it offers discounts to patients who have insurance coverage – most especially when that practice is participating with the carrier.  When a practice is participating with a carrier, then part of the provider participation agreement addresses the fact that the provider agrees to collect all co-payments, file all charges, and collect all deductibles and co-insurance from the patient in exchange for being treated as in-network/participating.  By offering discounts to patients with coverage, the practice is not adhering to its contractual obligations.  NOTE that a “professional courtesy” and/or “insurance only billing” is the same as a discount – the patient is receiving a benefit (excused from payment obligation) that runs afoul of the provider’s contractual obligations (and in the latter case, runs afoul of federally recognized compliance guidelines).* 

*Please note that since this article was written, the Omnibus Rule has had some impact on this, in that a patient can request that a provider NOT submit a claim to his/her insurance carrier, and that request MUST be accommodated.  Such requests, legitimized by the Omnibus Rule, trump the contractual obligation of a provider to submit a claim pursuant to a participation agreement.

Furthermore, regardless of a practice’s participation status with commercial carriers, if the practice is a Medicare provider, then it must not discount below the fee charged to Medicare – and most especially, the Medicare allowable, as Medicare law prohibits you from submitting Medicare claims that contain charges substantially in excess of your usual charges.  If the discounts consistently dipped below the billed fees, then Medicare would deem that new lower price to be the practice’s standard/customary fee.  If this fee is below the Medicare allowable, then the practice would be leaving money on the table that otherwise could have been collectable!

As always, if your practice has any questions, please do not hesitate to contact us!