# Do you file a patient's insurance?



## Jackie1973 (Nov 3, 2011)

I'm getting conflicting information and need to get the correct answer.  If a patient has a private policy and their ded is extremely high and they haven't met it and they wish to not file the insurance and just pay for the service.  Can they legally do this?

Thank you


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## ajs (Nov 3, 2011)

Jackie1973 said:


> I'm getting conflicting information and need to get the correct answer.  If a patient has a private policy and their ded is extremely high and they haven't met it and they wish to not file the insurance and just pay for the service.  Can they legally do this?
> 
> Thank you



Yes.  If you are not contracted with the insurance you are under no obligation to file a claim for the patient, so if they choose to pay at time of service and not file a claim, that is their right.  

If you are contracted with an insurer and a patient requests that you not bill their insurance, have them sign a waiver stating they do not want their insurance billed.


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## Jackie1973 (Nov 3, 2011)

Thank you for the information...  Where would I find a waiver?  All we have in the office is the CLIA Waviers?


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## mitchellde (Nov 3, 2011)

My question is why would they not want you to file with the carrier if they have not met the deductible if they plan to pay out of pocket anyway?  That makes no sense, it seems they would want the amount captured to go toward the deductible.  what am I missing here?


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## Jackie1973 (Nov 3, 2011)

Our company has a program where we can take proof of income and adjust the amount of the charges by where they fall in the guidelines.


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## cansas (Nov 3, 2011)

My experience has been, because the patients think "I am going to have to pay for this anyway."  Usually I try to educate the patient on the benefits of sending it to their insurance so it is applied appropriately to their deductible.  That usually does the trick and we are okay.  Depending on contract the patients frequently pay less after insurance processes it because of allowables. etc.


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## ajs (Nov 3, 2011)

Jackie1973 said:


> Thank you for the information...  Where would I find a waiver?  All we have in the office is the CLIA Waviers?



You can create your own waiver or "google" is a good resource for finding information on creating various types of waivers.


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## ajs (Nov 3, 2011)

cansas said:


> My experience has been, because the patients think "I am going to have to pay for this anyway."  Usually I try to educate the patient on the benefits of sending it to their insurance so it is applied appropriately to their deductible.  That usually does the trick and we are okay.  Depending on contract the patients frequently pay less after insurance processes it because of allowables. etc.



I also would educate the patient on why it is a good practice to submit a claim so the amount is applied to the deductible.  In the case that was presented, the patient had a private insurance, so it would appear the provider is not contracted.  If you are not contracted there is generally no allowable write off, so the patient should pay at time of service and you can submit the claim as a courtesy, or give the patient the info they need to submit a claim on their own.

If you are contracted with the insurance, many of them have websites now where you can plug in the code for the visit and get the allowable amount.  Have the patient pay the amount you anticipate they will owe and submit the claim for them so it gets applied to their deductible.

I have had patients in the past who did not want a particular visit billed to the insurance because they don't want a record of it in their insurance history.  This would happen with pregnancy tests or birth control for teens, STD exams for an unfaithful spouse, or people afraid their employer would find out they came to the doctor for mental health issues, and other scenarios like this.


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## mitchellde (Nov 3, 2011)

But you cannot hide a diagnosis from a patient's payer.  I believe your contract with the payer will tell you this.  And you cannot adjust your charges if they have insurance.  Just because they have a high deductible does not mean we can treat them as a self pay, this is the danger of have a separate fee schedule for self pay.  You should not.  If they have insurance and they feel the deductible amount is more than they can afford then it is really up to the insurance as to whether you can charge less then they would ordinarily have to pay.


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## ajs (Nov 3, 2011)

mitchellde said:


> But you cannot hide a diagnosis from a patient's payer.  I believe your contract with the payer will tell you this.  And you cannot adjust your charges if they have insurance.  Just because they have a high deductible does not mean we can treat them as a self pay, this is the danger of have a separate fee schedule for self pay.  You should not.  If they have insurance and they feel the deductible amount is more than they can afford then it is really up to the insurance as to whether you can charge less then they would ordinarily have to pay.



You are not hiding a diagnosis from a payer if the patient is not presenting a claim for those services. Not submitting a claim for services does not affect the payer.  You might be hiding a diagnosis from a parent, spouse or employer. 

The patient is the consumer for the insurance carrier, so they can direct if they do not want a claim sent to their insurance carrier.  You as a contracted provider are only obligated to submit a claim if the patient presents with an insurance you are contracted with, and requests you submit a claim.  But the patient can choose not to use their insurance benefits, you just need a waiver on file for your records that it was the patient's decision to pay at time of service to not submit an insurance claim.  The patient can also come back at a later date and ask to have the claim submitted to the payer. 

We never adjusted the charges based on having insurance or not, we just found out what the insurance allowable is up front and had the patient pay that amount when we already knew that they had a large deductible that was not yet met.  It is allowed to collect insurance deductibles, coinsurances and copays at the time of service.  With so many health plans going to high deductibles, it is one way providers can collect what is owed to them up front, and it is allowed per the insurance contracts.


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## mitchellde (Nov 3, 2011)

the insurance adjusts premiums and benefits on the basis of a patients profile which is made up of the diagnosis we submit, then to not submit a claim is in fact hiding certain diagnosis from the payer. The patient may not want to be denied life insurance or is wanting to apply for a different job and does not want a condition to be pre exisiting.  Think about things like HIV, STDs Cancer Hepatitis, we cannot not report these things and others to the patient's payer.  
Also FYI was not implying you were discounting the charges I just wanted to throw that in as it is something I hear often.


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## ajs (Nov 3, 2011)

mitchellde said:


> the insurance adjusts premiums and benefits on the basis of a patients profile which is made up of the diagnosis we submit, then to not submit a claim is in fact hiding certain diagnosis from the payer. The patient may not want to be denied life insurance or is wanting to apply for a different job and does not want a condition to be pre exisiting.  Think about things like HIV, STDs Cancer Hepatitis, we cannot not report these things and others to the patient's payer.
> Also FYI was not implying you were discounting the charges I just wanted to throw that in as it is something I hear often.



But the bottom line still is that the insurance belongs to the patient, not the provider.  What about the case where they are new and don't tell you they have insurance?  Or the insurance has changed and they decide not to tell you they have insurance?  All the situations you described are true, but it is not the provider's responsibility to be the insurance police.  Would you rather treat the patient and not bill the insurance, or risk the patient not receiving treatment because you refused their request to not bill insurance?


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## mhstrauss (Nov 3, 2011)

mitchellde said:


> the insurance adjusts premiums and benefits on the basis of a patients profile which is made up of the diagnosis we submit, then to not submit a claim is in fact hiding certain diagnosis from the payer. The patient may not want to be denied life insurance or is wanting to apply for a different job and does not want a condition to be pre exisiting.  Think about things like HIV, STDs Cancer Hepatitis, we cannot not report these things and others to the patient's payer.
> Also FYI was not implying you were discounting the charges I just wanted to throw that in as it is something I hear often.



Just 1 other point to this...if a patient is applying for life insurance, etc, the life insurance company should be requesting records from the provider, so they will likely find out about any conditions the patient may have by reviewing records, regardless of whether or not health insurance claims were filed.


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