Practice Management

Our practice understands that patients have the right under HIPAA to restrict PHI sharing with their payers and be a self pay status but if the patient just wants to be a Self Pay status due to high deductible or their authorization is pending and they do not want to wait- how do you handle these requests to become a true Self pay status?  Is signing a Self Pay form noting they understand they are Self Pay and cannot submit for insurance reimbursement after the fact enough to protect the practice?   We recently had this very situation where the auth was pending, the patient chose to be Self Pay and move ahead  (signing the form) and then 2 days later the auth was approved and then the patient wanted their money refunded and us to bill the insurer.    The insurance companies do not take this process well when contacted by their clients and have claimed we are in violation of our contract.

Anyone have suggestions or willing to share their processes?

------------------------------
Vicki Melendez
Radiology Regional Center
Fort Myers FL
239-936-2316
------------------------------

Per my experience if the patient doesn't want to wait for pre-auth then we enter into a direct relationship with the patient and have them sign an agreement to that fact.

Worse yet, we see patients in chronic serious pain and insurers take their time deciding if a scan is necessary.

Not good for anyone.

In short - if the patient doesn't want to wait (and pre-auth is ALWAYS an issue) then they waive their rights to bill their insurer.

But...of course better to enter into a private agreement with the patient before sending any info to the insurer but this is often impractical.

A problematic situation at best and the best option may be for THE PATIENT to contact their insurer and either insist on a quick auth or advise that THEY HAVE PROACTIVELY CHOSEN to waive insurance.

There may be restrictions on Medicare patients.

Re: pre-auth...less than 5% of requested MRI scans are not authorized.

In consideration of the burden this causes for referring physicians, imaging centers and the delay in patient care...

I have a great idea!

Why don't the insurers just reduce compensation by 5% and waive the pre-auth requirement?

Everyone wins!

And insurers have the right to audit and if it's not medically necessary speak with the referring physician!

Would anyone object to a reduction in reimbursement in this case?

PATIENTS WOULD BE SEEN PROMPTLY - and as we are in the business of helping the sick who is the faceless, nameless person who actively works to pay less and ultimately delay patient care.

MADNESS!




------------------------------
William Kisse
COO
Washington Open MRI, Inc.
Rockville, MD
bill@womri.com
(301) 424-4888
https://www.linkedin.com/in/billkisse/
------------------------------

Original Message:
Sent: 02-24-2021 12:47
From: Vicki Melendez
Subject: Self Pay when not HIPAA related

Our practice understands that patients have the right under HIPAA to restrict PHI sharing with their payers and be a self pay status but if the patient just wants to be a Self Pay status due to high deductible or their authorization is pending and they do not want to wait- how do you handle these requests to become a true Self pay status?  Is signing a Self Pay form noting they understand they are Self Pay and cannot submit for insurance reimbursement after the fact enough to protect the practice?   We recently had this very situation where the auth was pending, the patient chose to be Self Pay and move ahead  (signing the form) and then 2 days later the auth was approved and then the patient wanted their money refunded and us to bill the insurer.    The insurance companies do not take this process well when contacted by their clients and have claimed we are in violation of our contract.

Anyone have suggestions or willing to share their processes?

------------------------------
Vicki Melendez
Radiology Regional Center
Fort Myers FL
239-936-2316
------------------------------

Good Morning Vicki and William,

Suggesting a reduction in payment for eliminating radiology benefits management companies processes is a slippery slope IMHO and really should not be necessary. Equally, if you have true medical necessity your referring physician should be willing to submit their medical records documenting conservative treatment and clinical indications which support the need for the procedure. As such payment should eventually be approved. So, why take another reduction in a world were the allowable is already shrinking?

Some years ago I created an insurance company version of the Medicare ABN. Using the government model provides you with a sound legal precedence for the legality of the financial responsibility form itself. That said, it is always good to run these things by your attorney for legality in your state. 

The Insurance Company ABN included a paragraph stating:
I want [insert name of procedure being performed] listed above. You may ask to be paid now, but I also want [insert name of 3rd party payer] billed for an official decision on payment, which is sent to me on an explanation of benefits Notice. I understand that if [insert name of 3rd party payer] doesn't pay, I am responsible for payment, but I can appeal to [insert name of 3rd party payer] by following the directions of the payer. If [insert name of 3rd party payor] does pay, you will refund any payments I made to you, less co-pays or deductibles.

Reason Payer May Not Pay: patient chose to proceed with procedure listed above or [insert name of procedure being performed] without waiting for official pre-authorization approval by [insert name of payer].

You may want to consider running this process by certain payers if you wish. I do not recall ever having an insurance company claim we were in violation with our contract in these situations.

I hope you find this helpful!
Steve

------------------------------
Steve Schreiber FRBMA
Director of Marketing General Manager Radiology Business
HealthLevel
Mountain View CA
------------------------------

Original Message:
Sent: 03-25-2021 10:36
From: William Kisse
Subject: Self Pay when not HIPAA related

Per my experience if the patient doesn't want to wait for pre-auth then we enter into a direct relationship with the patient and have them sign an agreement to that fact.

Worse yet, we see patients in chronic serious pain and insurers take their time deciding if a scan is necessary.

Not good for anyone.

In short - if the patient doesn't want to wait (and pre-auth is ALWAYS an issue) then they waive their rights to bill their insurer.

But...of course better to enter into a private agreement with the patient before sending any info to the insurer but this is often impractical.

A problematic situation at best and the best option may be for THE PATIENT to contact their insurer and either insist on a quick auth or advise that THEY HAVE PROACTIVELY CHOSEN to waive insurance.

There may be restrictions on Medicare patients.

Re: pre-auth...less than 5% of requested MRI scans are not authorized.

In consideration of the burden this causes for referring physicians, imaging centers and the delay in patient care...

I have a great idea!

Why don't the insurers just reduce compensation by 5% and waive the pre-auth requirement?

Everyone wins!

And insurers have the right to audit and if it's not medically necessary speak with the referring physician!

Would anyone object to a reduction in reimbursement in this case?

PATIENTS WOULD BE SEEN PROMPTLY - and as we are in the business of helping the sick who is the faceless, nameless person who actively works to pay less and ultimately delay patient care.

MADNESS!




------------------------------
William Kisse
COO
Washington Open MRI, Inc.
Rockville, MD
bill@womri.com
(301) 424-4888
https://www.linkedin.com/in/billkisse/

Original Message:
Sent: 02-24-2021 12:47
From: Vicki Melendez
Subject: Self Pay when not HIPAA related

Our practice understands that patients have the right under HIPAA to restrict PHI sharing with their payers and be a self pay status but if the patient just wants to be a Self Pay status due to high deductible or their authorization is pending and they do not want to wait- how do you handle these requests to become a true Self pay status?  Is signing a Self Pay form noting they understand they are Self Pay and cannot submit for insurance reimbursement after the fact enough to protect the practice?   We recently had this very situation where the auth was pending, the patient chose to be Self Pay and move ahead  (signing the form) and then 2 days later the auth was approved and then the patient wanted their money refunded and us to bill the insurer.    The insurance companies do not take this process well when contacted by their clients and have claimed we are in violation of our contract.

Anyone have suggestions or willing to share their processes?

------------------------------
Vicki Melendez
Radiology Regional Center
Fort Myers FL
239-936-2316
------------------------------

Thank you, Steve!

All points understood.

My comment about 'reduction' in reimbursement is solely based on cost/benefit.

I DON'T WANT TO GO DOWN THAT SLIPPERLY SLOPE, but what's a reasonable alternative that meets the needs of all?

The burden on our staff to receive and forward appropriate physician notes outweighs the 5% reduction.

We are in the business of serving sick patients ASAP, and the burden of pre-auth paperwork delays plus hours spent on the phone/email only serves to delay prompt testing of patients.

Regards

Bill

------------------------------
William Kisse
COO
Washington Open MRI, Inc.
Rockville, MD
bill@womri.com
(301) 424-4888
https://www.linkedin.com/in/billkisse/
------------------------------

Original Message:
Sent: 03-25-2021 11:29
From: Steve Schreiber
Subject: Self Pay when not HIPAA related

Good Morning Vicki and William,

Suggesting a reduction in payment for eliminating radiology benefits management companies processes is a slippery slope IMHO and really should not be necessary. Equally, if you have true medical necessity your referring physician should be willing to submit their medical records documenting conservative treatment and clinical indications which support the need for the procedure. As such payment should eventually be approved. So, why take another reduction in a world were the allowable is already shrinking?

Some years ago I created an insurance company version of the Medicare ABN. Using the government model provides you with a sound legal precedence for the legality of the financial responsibility form itself. That said, it is always good to run these things by your attorney for legality in your state.

The Insurance Company ABN included a paragraph stating:
I want [insert name of procedure being performed] listed above. You may ask to be paid now, but I also want [insert name of 3rd party payer] billed for an official decision on payment, which is sent to me on an explanation of benefits Notice. I understand that if [insert name of 3rd party payer] doesn't pay, I am responsible for payment, but I can appeal to [insert name of 3rd party payer] by following the directions of the payer. If [insert name of 3rd party payor] does pay, you will refund any payments I made to you, less co-pays or deductibles.

Reason Payer May Not Pay: patient chose to proceed with procedure listed above or [insert name of procedure being performed] without waiting for official pre-authorization approval by [insert name of payer].

You may want to consider running this process by certain payers if you wish. I do not recall ever having an insurance company claim we were in violation with our contract in these situations.

I hope you find this helpful!
Steve

------------------------------
Steve Schreiber FRBMA
Director of Marketing General Manager Radiology Business
HealthLevel
Mountain View CA

Original Message:
Sent: 03-25-2021 10:36
From: William Kisse
Subject: Self Pay when not HIPAA related

Per my experience if the patient doesn't want to wait for pre-auth then we enter into a direct relationship with the patient and have them sign an agreement to that fact.

Worse yet, we see patients in chronic serious pain and insurers take their time deciding if a scan is necessary.

Not good for anyone.

In short - if the patient doesn't want to wait (and pre-auth is ALWAYS an issue) then they waive their rights to bill their insurer.

But...of course better to enter into a private agreement with the patient before sending any info to the insurer but this is often impractical.

A problematic situation at best and the best option may be for THE PATIENT to contact their insurer and either insist on a quick auth or advise that THEY HAVE PROACTIVELY CHOSEN to waive insurance.

There may be restrictions on Medicare patients.

Re: pre-auth...less than 5% of requested MRI scans are not authorized.

In consideration of the burden this causes for referring physicians, imaging centers and the delay in patient care...

I have a great idea!

Why don't the insurers just reduce compensation by 5% and waive the pre-auth requirement?

Everyone wins!

And insurers have the right to audit and if it's not medically necessary speak with the referring physician!

Would anyone object to a reduction in reimbursement in this case?

PATIENTS WOULD BE SEEN PROMPTLY - and as we are in the business of helping the sick who is the faceless, nameless person who actively works to pay less and ultimately delay patient care.

MADNESS!




------------------------------
William Kisse
COO
Washington Open MRI, Inc.
Rockville, MD
bill@womri.com
(301) 424-4888
https://www.linkedin.com/in/billkisse/

Original Message:
Sent: 02-24-2021 12:47
From: Vicki Melendez
Subject: Self Pay when not HIPAA related

Our practice understands that patients have the right under HIPAA to restrict PHI sharing with their payers and be a self pay status but if the patient just wants to be a Self Pay status due to high deductible or their authorization is pending and they do not want to wait- how do you handle these requests to become a true Self pay status?  Is signing a Self Pay form noting they understand they are Self Pay and cannot submit for insurance reimbursement after the fact enough to protect the practice?   We recently had this very situation where the auth was pending, the patient chose to be Self Pay and move ahead  (signing the form) and then 2 days later the auth was approved and then the patient wanted their money refunded and us to bill the insurer.    The insurance companies do not take this process well when contacted by their clients and have claimed we are in violation of our contract.

Anyone have suggestions or willing to share their processes?

------------------------------
Vicki Melendez
Radiology Regional Center
Fort Myers FL
239-936-2316
------------------------------