Practice Management

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  • 1.  Opting out of using Commercial insurance in lieu of Self Pay Options

    Posted 06-06-2023 13:12

    Is there a consensus in how practices should handle self-pay requests from patients when they ask to opt out of using their commercial insurance?   This question is focused on services that are NOT covered by their insurance, such as PRP injections, or venous surgeries.   We're getting various opinions from compliance and legal perspectives that insurance must be billed in all cases...which of course, returns denials that, for the most part, reflect zero patient responsibility.

    This question is NOT related to high deductible plans or standard medically necessary covered services, a question we get occasionally from patients.   Any commentary on essentially a patient's right to request we NOT bill their insurance, (in this case for services that will NOT be covered by their insurance), is appreciated, thanks!



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    Dennis J Chaltraw, CRCE
    Director Revenue Cycle Management
    Oregon Imaging Centers / Radiology Associates / ReNew Vascular Institute
    dchaltraw@oregonimaging.com
    Eugene OR
    541-302-7771
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  • 2.  RE: Opting out of using Commercial insurance in lieu of Self Pay Options

    Posted 06-06-2023 13:36

    Dennis – I have always been advised the patient has the right to direct who does and does not receive notification of a medical service. If they do not want their insurance notified – it's the patient's choice.

     

    I deal with this by trying to get groups to develop a document for patients to execute that does a few things:

                 

    1. States that the Patient is directing the provider NOT to submit a claim to their insurance.
    2. The Patient accepts 100% financial responsibility for the services being delivered.
    3. The Patient will be provided a 25% (or whatever percent the group is comfortable with) discount from the normal charge if the service is paid for at time of delivery. If not, then the full charge will apply.

     

    I have a receptionist witness the signature of the patient.

     

    This creates a legally binding document between the practice and the patient which will survive a challenge in small claims court which is where these usually go if the patient tries to evade payment.

     

    I'm trying to figure out if we can add language that has the patient wave their right of non-reporting to the credit bureau of any unpaid balance on the claim if the amount outstanding is below the $500 reporting limit, but I have not been able to get a definitive answer on that one.

     

    Hope this helps.

     

     

    Keith E. Chew, MHA, CMPE, FRBMA

    Principal

    Consulting with Integrity

    18 Hawks Nest

    Chatham, IL     62629

    217-971-5293

     




    Original Message


  • 3.  RE: Opting out of using Commercial insurance in lieu of Self Pay Options

    Posted 06-06-2023 13:37

    Under HIPAA, patients do have a right to request that an insurance claim not be filed.  You also have a right to require payment at the time of service in such a case.

    See https://www.hhs.gov/hipaa/for-professionals/faq/3026/under-hipaa-may-an-individual-request-that-a-covered-entity-restrict-how-it-uses-or-discloses-that-individuals-protect-health-information/index.html\

    Since Medicare participation and most insurance contracts require that a claim otherwise be filed for covered services, you would want to get that request in writing from the patient.  I would also ask the patient to agree in writing not to request that a claim be filed at a later date.  I have heard of patients coming back later with a request to file, which then results in a denial due to no authorization, timely filing, or other circumstances, resulting in no patient liability and leaving the provider holding the bag.

    You would have to read your actual contracts, but I think insurance contracts generally frame the filing requirement in the context of covered services, so it may not be required to file a claim for services that are never covered (cosmetic procedures, for example).  I'm not sure about any Medicare filing requirements with respect to services that are never covered.

    Either way, if you get the patient request in writing you should be clear not to file.



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    David Smith FACMPE
    Executive Director
    United Imaging Consultants
    Mission KS
    (785) 393-8387
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    Original Message


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