Forum - Questions & Answers

Nov 9th, 2022 - Goose 1 

Billing specific codes only to specific insurance companies

Can I pick and choose which insurance companies I bill specific codes to? for instance can I bill a code to BWC but if I have a patient that has Anthem and I want to perform the same procedure code on that patient but charge them cash and not bill their insurance?

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Nov 14th, 2022 - ChrisW   254  1 

re: Billing specific codes only to specific insurance companies

There are an increasing number of providers willing to give cash discounts for a patient not using their insurance, and in addition, yes, patients can request that their insurance is NOT billed if they chose to pay out of pocket. All patients billing and claim information is protected under HIPAA, and it is up to the patient how they want their medical information handled. However, it is important to review each payer’s contract to see how your contracts want it managed. Each payer may have their own forms the patient needs to fill out. If you have a contract with any payer, you are subject to their contracts, which may include how you bill your patient, although they are also required to follow HIPAA rules. If the patient does not want you to bill their insurance, you will need to collect payment in full. Medicare providers are required to send in a claim identifying there is an ABN on file using the appropriate modifier; without the ABN on file (with the beneficiary’s signature and date), you will not receive reimbursement.In addition, anytime a patient asks not to have their insurance billed, it is vital you have something in writing attesting to the restriction of billing their insurance. Otherwise, it could come back on you, and you may not get paid for the service due to filing times or other circumstances.  In addition, inform the patient this amount will not be applied toward their deductible and that the claim cannot be appealed.  This information is covered under Section 13405 of the HIPPA/HITECH actRESTRICTIONS ON CERTAIN DISCLOSURES AND SALES OF HEALTH INFORMATION; ACCOUNTING OF CERTAIN PROTECTED HEALTH INFORMATION DISCLOSURES; ACCESS TO CERTAIN INFORMATION IN ELECTRONIC FORMATREQUESTED RESTRICTIONS ON CERTAIN DISCLOSURES OF HEALTH INFORMATION.-In the case that an individual requests under paragraph (a)(1)(i)(A) of section 164.522 of title 45, Code of Federal Regulations, that a covered entity restrict the disclosure of the protected health information of the individual, notwithstanding paragraph (a)(1)(ii) of such section, the covered entity must comply with the requested restriction if- o    Except as otherwise required by law, the disclosure is to a health plan for purposes of carrying out payment or health care operations (and is not for purposes of carrying out treatment); and ·         The protected health information pertains solely to a health care item or service for which the health care provider involved has been paid out of pocket in full. Reference: Section 13405 ofFull act here:  https://www.healthit.gov/sites/default/files/hitech_act_excerpt_from_arra_with_index.pdf

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Nov 21st, 2022 - Goose 1 

re: Billing specific codes only to specific insurance companies

Do I have to offer that patient the option or can I just charge them cash and not give them the choice to bill their insurance.  In this instance, I am a provider for their insurance company.

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Nov 28th, 2022 - ChrisW   254  1 

re: Billing specific codes only to specific insurance companies

I would highly suggest you review your contracts prior to charging them cash prices. I would also recommend you always have a signed acknowledgment from the patient, showing they understand you are not billing their insurance.  This can help prevent a patient from being told by their insurance that they do not need to pay you due to filing times, pre-authorization, or a number of other reasons if you have a contract with the payer.


You may consider opting out of your contractual obligations, this way members are not being referred to you by their insurance as a preferred provider. 


Here are a few articles that may help. 


Basic steps for starting your good faith estimate compliance


Legal: Can a patient opt out of insurance, even if we’re an In-Network or Out-of-Network Provider?


 

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