Orthopedic Coding Alert

Question: Can you please help us understand if it is better to bill the patient for DME instead of sending the claim to the insurance? The ortho office feels they can get more from the patient than the insurance will pay. The patient signs a waiver. Do the payer contracts not stipulate all covered procedures must be submitted to the payer? Please advise.

Ohio Subscriber

Answer: You are correct to be concerned about contract language.  Before further consideration is given to billing the patient directly, a review of all managed care contracts must be undertaken.

Billing would primarily depend upon whether the provider is "participating" or "non-participating" with Medicare. Private insurances could have their own rules.

If it is a Medicare patient and the practice has agreed to be a "participating supplier" with Medicare, then the practice must accept the Medicare payment amount for the item. Even if a "participating supplier" gets an ABN signed, that still would not allow them to charge more than Medicare is willing to pay. Here is a link to a document that explains this: http://www.medicare.gov/publications/pubs/pdf/11045.pdf

If it's a private insurer, then it would depend on that insurer's rules and state laws, and they vary widely. They would have to contact a health care attorney in their state to be sure.