Wiki Billing a patient for a service without submitting to insurance

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zory616

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I have some providers that would like to charge a patient $20 for a B12 injection and not submit it to insurance at all when they are in the office for other services. I'm questioning the legality of this.

For example, a patient with insurance is seen for a sick visit and gets labs and a steroid shot. They pay their copay for this. Can we skip billing the insurance for the B12 drug and admin, and charge the patient right away for the $20?

The reason for this is that some plans aren't covering B12 and the providers want to follow the same guidelines for every patient instead of having to remember which insurance is going to cover it or not.

Thanks so much in advance!
Zory
 
re:

From what I have learned from our Legal team, is that is not ok, unless you know it is not medically necessary. Part of the issue comes in that you may be charging less to certain patients than what insurance reimburses, and if that plan in particular would be paying more, it could be considered fraud. It would be best to follow the same guidelines for every patient, and if it is a medically necessary procedure bill to insurance whether or not it is a covered service, and then bill the patient what insurance deems pt responsibility after the claim has processed.

Would love to hear others opinions and thoughts on this as well!
:D
 
b12 shots self pay

What you offer to one, you offer to all. The process can be multi-fold...
If the doctor wants to give the shot that day and there is a coworker available to check the benefits, then you ask the patient to sign a waiver if it is not covered and they pay up front. You still bill the insurance for the proper denial however, you just have your payment up front.
If the provider wants to give an injection and no one can verify, see if the patient can come back to see a nurse just for the shot after verification later that day or next day.
If the provider wants to give an injection and no one can verify, ask the patient to sign a waiver stating you aren't sure if it is a covered expense and pay. Still bill the insurance with the proper diagnoses, etc. If they deny you have your payment and if they pay you have to reimburse the patient.
Covered or non-covered, you still bill the insurance company however. The difference is knowing up front prior to the service if they cover it or not. Verify your main carriers now to know for February what is covered... Aetna, Cigna, BCBS, etc - what situations do they cover it for and which ones don't. Then you have that policy that says... your insurance doesn't cover this service, you will need to pay up front.
A way to think of it is... would you not bill medicare for a service? You already know which ones they pay and under what circumstances they pay and not pay. Medicare asks you have the patient sign a waiver and then bill the insurance with the proper modifier indicating that the patient has been made aware. Should be the same with all carriers.
Jennifer Sanders, CPC, CPB, CPC-I, Fellow
 
I appreciate your responses!I think it'll be best to research every insurance's reimbursement policies and go from there. I'll pass this along - thank you :)
 
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