# Patients not using insurance with contracted providers.



## Nikadee (Jan 9, 2015)

I need help explaining to some mental health providers that have been allowing their patients to not use their insurance even through all of them are  contracted with those insurance companies.  I tried to explain to them that for the insurances they are contracted with they can't do that.  I contacted the insurance companies and they gave me the location in the contract it has that information but now these providers think it is still OK because the contract was very vague and not specific.  Can anyone out there help me in finding more specific information that isn't so vague on this issue??  Thankfully I didn't take these providers on as billing clients but I would like to get this clarified for them to try to keep them out of trouble.  THANKS VERY MUCH!!


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## TThivierge (Jan 10, 2015)

Hello
This is the call of the therapist. They should bill the insurance and list the patient's proper diagnosis. If the therapists refuses to bill the client's diagnosis or does not want it billed  I do not think you can do anything...because they give the diagnosis code.  Some therapist feel this may label the client with a mental health dx. if he or she is a young teen just making mistakes . The teen maybe not have severe  mental problem just stressed a bit. And if the therapists first visit codes of 799.9 or a V code of minor problem the insurance will not pay. 

Ahh, I know it is a crappy situation.


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## mitchellde (Jan 10, 2015)

TThivierge said:


> Hello
> This is the call of the therapist. They should bill the insurance and list the patient's proper diagnosis. If the therapists refuses to bill the client's diagnosis or does not want it billed  I do not think you can do anything...because they give the diagnosis code.  Some therapist feel this may label the client with a mental health dx. if he or she is a young teen just making mistakes . The teen maybe not have severe  mental problem just stressed a bit. And if the therapists first visit codes of 799.9 or a V code of minor problem the insurance will not pay.
> 
> Ahh, I know it is a crappy situation.



The dx code comes from the documentation not from what the therapist wants billed as a code.  The code must match what is documented in the note regardless of the code the therapist gives.  The code number on the claim does not have to match the code number the therapist or physician chooses but it must match the narrative diagnosis in the note.  
If the patient does not reveal that they have insurance then you have no problem, however if you are contracted with the payer and they patient does reveal they are a subscriber with that payer then I don't think you have any choice but to bill the claim.  I think you could call the payer and ask or contact an attorney skilled in healthcare issues to answer this definitively.  It is a slippery slope when the patient wants to withhold information from the payer whom they as the patient are also contracted with.


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## bonn715 (Jan 24, 2015)

in the practice i work for, we have an agreement with the state Attorney General to bill the patient's insurance or we cannot collect the balance from them.  A liability waiver is a way around it or the patient can pay up front, which we have set aside accounts for to show they waived billing the insurance.  The problem with not billing the patient's insurance (for instance if they never gave it to us) is that later, after timely filing limitations, they can say they wanted the insurance billed and we didnt bill it. so if it went to collections, it has to be recalled, rebilled, and denied for timely and written off.  If they are insisting on not billing the insurance, it would probably be wise to have it documented somewhere and check with your administration to see if there is any state law or agreement in regards to what you have to bill to the insurance or even check with your compliance department


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