# Out of Network Payment To Patient



## suemt (Apr 9, 2011)

I have a situation and I'm not sure how to address.  

The surgeon is out of network and there is one insurance company that pays the patient!  While some patients forward the payment to the doctor, there are too many who seem to treat the $15,000 checks like they've won the lottery and do not pay even though they have signed a promise to pay.    

The amount is too much to go to small claims court, we can't refuse to treat them, and trying to collect by hiring an attorney could eat up all the payment anyway, especially since the patients who do this are usually financially challenged and the money has been spent before we could do anything about it anyway.  

I want to camp at the patient's mailbox and take them by limo to the bank when the check arrives, but I'm sure there is a more practical solution.  

Thanks in advance for any advice.


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## btadlock1 (Apr 9, 2011)

suemt said:


> I have a situation and I'm not sure how to address.
> 
> The surgeon is out of network and there is one insurance company that pays the patient!  While some patients forward the payment to the doctor, there are too many who seem to treat the $15,000 checks like they've won the lottery and do not pay even though they have signed a promise to pay.
> 
> ...



Did you have the patient sign an assignment of benefits form, when they registered? If so, you should have indicated that they authorized for the payment to be sent to you... (in box 13 on the CMS1500, or box 53a, b, and c on the UB04)

Depending on where you're located, it may not be legal for the insurer to pay the patient, as this article demonstrates:http://jacksonville.com/news/metro/...rk_doctors_to_be_paid_directly_by_insurance_c

Check with your state's department of insurance for more information for your state. I'd also recommend checking the insurer's website for a disclosure regarding how out of network claims are paid. Unless you can get the insurer to reverse their payment, by citing claim instructions, state laws, or their own payment policies, you're kind of stuck collecting payment on your own. The best you can probably do at that point is turn them over to a collection agency and ruin their credit.

Hope that helps!


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## suemt (Apr 10, 2011)

Brandi, thanks for your reply.  

This is a BIG insurer, and the billers are pretty savvy, so I'm reasonably sure they aren't doing something wrong, although we'll double check all your suggestions.  

This doc is in NY, so the FL law you cite doesn't apply to this case.  But it is good to know for my FL clients.  

And as far as ruining their credit, these patients are usually pretty indigent, so there would be no credit to ruin.  

Thanks again!  This group is such a great resource.

Sue


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## MMAYCOCK (Apr 10, 2011)

*OON Payer*



suemt said:


> I have a situation and I'm not sure how to address.
> 
> The surgeon is out of network and there is one insurance company that pays the patient!  While some patients forward the payment to the doctor, there are too many who seem to treat the $15,000 checks like they've won the lottery and do not pay even though they have signed a promise to pay.
> 
> ...



We have this issue with BCBS of MI. Our system was to tell the patients prior to treatment that the payment would be coming to them and to have them sign a lien for agreeing to send the payment (lien forms are much more effective than the standard agreement other patients sign). I also assigned someone to follow the claim status online- our BCBS online provider resource is called WEBDENIS- and to call the patient when we see that the check was sent. BCBS shows the payment info before the payments are sent out. Calling the patient, telling them the amount they were receiving and asking them again to send it in endorsed to us has improved our collection on these by over 89%.


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## suemt (Apr 10, 2011)

This sounds like a very viable solution.  

Where did you get lien forms?  Would we need an attorney to prepare these, or is it literally a form?  I'm not familiar with this.


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## acombspsa (Apr 13, 2011)

We have the same problem with Bluecross NC. It should be illegal to send the check to the policyholder! It is a tactic to try to persuade providers to sign a contract, because they are counting on their insureds' dishonesty. We would really appreciate any suggestions on how to collect these payments because we have tried everything.


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## MMAYCOCK (Apr 13, 2011)

*OON payments*



suemt said:


> I have a situation and I'm not sure how to address.
> 
> The surgeon is out of network and there is one insurance company that pays the patient!  While some patients forward the payment to the doctor, there are too many who seem to treat the $15,000 checks like they've won the lottery and do not pay even though they have signed a promise to pay.
> 
> ...


Have you tried having patients sign a lien form? Not the usual assignment form because BCBS does not honor that, but a lien form such as what would be used for work comp and auto patients.


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## AAPC261 (Jun 18, 2011)

how can i get a lein form?


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## wannabecoder (Jun 18, 2011)

The other things to do would be to check and see if the payor has a nonpar provider relations rep to see about why this happens. Also contacting your states Insurance Commissioner or Business Dept would be another thing to check into to see how or if there has ever been any complaints or solutions for your situation or file a complaint your self.  

That seems very odd that that large of a dollar amount has to be paid to the insured. Well good luck, it appears there are some viable solutions here.


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## btadlock1 (Jun 19, 2011)

I believe that's through the court - see here:
http://www.ehow.com/how_4474810_file-lien-online.html


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## jennsomers (Jun 20, 2011)

I have OON doctors in NY and the patients do keep the checks. I make a call to them about getting the checks sent in. If that doesnt work and they do not pay,  as well as sending them to collections, I send a letter than explains that I will be contacting the insurance co and asking them to issue the pt a 1099 so they can report it to the IRS as income. I then fill out a form for the IRS asking them to check that this income was actually reported. If the scare of an IRS audit doesnt make them pay... nothing will. 

I do have a good collections company that I use. I have sent them high balances and have had no issues. If you email your info, I can have the account manager call you. If its a referral from another dr, they may give you better rates. 

jennifer.medicalbilling@yahoo.com


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## penguins11 (Jun 23, 2011)

I would also research different collection agencies, some collection agencies are pretty agressive and will take these patients to court for you for a part of the payment received.  Also, when scheduling these patients for surgery or when you see them in follow up you may want to offer something like what you may for self pay patients. That if they pay or forward the check to you immediately you will accept what the insurance pays minus any copay or deductible,  If they do not, they will be responsible for the full amount of the bill.


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## zaidaaquino (Jun 24, 2011)

One of the things we do if we know we don't participate with a particular insurance, is to collect payment up front from the patient.  We then hand them a detailed receipt with codes so they can submit on their own.  

Zaida V Aquino, CPC


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