# Insured patients - Can they self/cash pay?



## MonarchMedBill (Oct 31, 2017)

There are 2 sides to my question:

1.)  Recently I came across a patient that was seen in our office for a specialist follow up visit.  The patient's insurance (BCBSTX) requires a referral from the PCP.  The PCP on file was contacted but stated he is not the patient's PCP, has only seen the patient once and would not give us the referral.  The patient's daughter confirmed that is who her mother states is the PCP. The patient has been seen 3 times in our office and each time paid a $40 copay.  The claims have all been denied for no referral.  We billed $360.00 for each visit, collected the $40 copay and then when the claim was denied the remaining $320 was adjusted off as not payable since we didn't obtain a referral.  The office kept the $40 as payment for services.  The office offers a discount to cash pay patients making office visits $60.  The reps that worked this claim before I came on board (2 months ago) accepted the $40 as payment in full - stating it wasn't the patients fault that a referral wasn't obtained.  I confirmed with a rep that the PT's plan only requires the $40 copay for the PCP visit.  Specialist visits have no copay but are subject to 70% coinsurance of allowed amount.

I believe in this case, we are required to refund the patient the $120 she has paid in copay amounts.  We can't bill the patient for coins or deductible since the claim was denied.  Is there any documentation from a legal standpoint that I can use to prove this to my employer?

2.)  In the notes I read that the plan is to let the patient know if we cannot obtain a referral from her PCP, she will have to be a cash pay patient and we will bill her $60 for all future visits.  This patient is subject to deductible and coinsurance responsibilities within her BCBSTX contract.  I am finding mixed reviews on letting insured patients pay cash.  I've read it is okay to bill the patient cash as long as we bill her the same thing we would bill the insurance - and that we can't offer her a discount if we don't offer them one.  I've read that we are required to submit the claim to the insurance and let them know how much she paid at the time of visit.  Either way I can't find anything from a reliable source to use for documentation.

HELP!


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## csperoni (Oct 31, 2017)

Since it is a commercial carrier, it depends mostly on your provider contract.  One carrier (I think it's Oxford), for example, will permit a patient to pay cash if a referral is not issued PROVIDED the patient is informed prior to the services and signs the specific insurance form.  Our patient demographics paperwork that includes a disclaimer about being responsible if there is no referral is not sufficient for that carrier.  
If this carrier does not specify in the contract, it is my opinion that you should refund anything already paid unless she was informed prior to the service.  It is also my opinion (if the contract does not specify otherwise) that you may treat her as a cash patient moving forward, but would have her sign something to that effect.  
Again, this is my OPINION and only if the provider contract does not address this issue.
Regarding a reliable source for documentation, if it is not in the provider contract, it is possible state health insurance law addresses the issue.


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## thomas7331 (Nov 1, 2017)

I agree with the previous post - for a commercial payer, under what circumstance and for how much you can bill the patient in this situation will largely depend on the terms of the contract.  

Regarding your second question, the 'rule' about having to bill the insurance the same amount as you would charge the patient is derived from the False Claims Act which requires that you accurately represent on your claims the amount that you would accept as payment in full.  However, you're in a little bit of a grey area here, because the false claims act is usually cited in cases where claim information is misrepresented in a way that results in or attempts to get an improper payment - in a case where the claims are denied and you are negotiating the discount with the patient to settle a debt, it may not rise to the same level of compliance issue.  

All that said, it's certainly true that self pay arrangements can pose a compliance risk, and my suggestion would be to work with your manager and/or compliance officer to develop an office policy and not try to work this out on a case-by-case basis.


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