Wiki Accept Assignment

[fantasyquill]

My understanding is that if you check the box to "accept assignment," by definition, means you are accepting that insurance's fee schedule and allowed amount as payment in full, regardless of whether you are contracted with them or not.
We have a few insurances that sneak through, paying a miniscule amount, some % of Medicare rate, that is much lower than our regular commercial insurance rates, but because this box is checked, we have no recourse. When you call them, they say they do not negotiate their rate.
Is anyone else out there having this problem? If so, how are you handling it?
Our hands feel tied, but it hardly seems it should be legal for a small insurance to pay a % of Medicare rates on a commercial claim and get away with it simply because we accept assignment.

 

[thomas7331]

Your understanding isn't quite correct here. 'Assignment of benefits' means that the patient has agreed to assign their benefits to the provider. In other words, they have agreed that instead of receiving their benefits (payment for a given service) from the insurance company, they have agreed to allow the provider to file a claim and received the payment of that benefit directly. So if you indicate 'accept assignment' on the claim, you are only telling the insurance company that you have authorization from the patient to receive that payment and that it should be issued to the provider and not to the patient. It does not mean that you have agreed to accept the insurance company's fee schedule as payment in full.

For some government-sponsored plans (e.g. Medicare and Advantage plans, Medicaid, TRICARE, work comp, etc.), there are laws that may require a provider to accept a fee as payment in full. But for commercial insurance plans, if your provider is not contracted with the company or plan, then the provider is not required to accept that fee as payment in full. If that is the case, then the patient can, and in many cases should, be billed for the balance due, unless there are other laws in the state where your provider practices which regulate what you can charge.

 

[csperoni]

I would just add that if you are out of network, you should be providing the patient with an estimate per the federal No Surprises Act. The insurance will not negotiate their rate. The patient is the one responsible.

 

[vhofmeister]

Wow, this is incorrect information. The insurance will try to negotiate but at a low QPA rate. Then you send to the IDR. The patient is not responsible to negotiate!

 

[sls314]

Wow, this is incorrect information. The insurance will try to negotiate but at a low QPA rate. Then you send to the IDR. The patient is not responsible to negotiate!

I don't see where anyone said that the patient was responsible for negotiating.

csperoni referred to circumstances where the patient would be responsible for the balance of the bill, not negotiating.

 

[CBLENNIE]

Wow, this is incorrect information. The insurance will try to negotiate but at a low QPA rate. Then you send to the IDR. The patient is not responsible to negotiate!

The No Surprises Act (NSA) doesn't apply to all out-of-network claims, and I don't see anything in the OPs information that leads me to think that this is a claim that would qualify under the NSA for the IDR process. Here is a quick snip of what is covered under the NSA per CMS.gov's website on the NSA linked here.


A provider can always try to negotiate with the insurance company but if those negotiations don't work out, they may be out of luck on this one if this doesn't qualify as a surprise billing.

Additionally, insurance companies typically do not negotiate the allowed amount applied to a claim from an out-of-network provider for a claim that is not a surprise billing with the patient directly.