Wiki Billing for post-operative care.

[Missy13]

I am being asked if post-operative care can be billed to self pay patients and out of network insurance, since the provider has no contract signed with them. From my knowledge surgical package rule should apply to everyone, in-network and out of network insurances as well as self pay patients. Am I wrong? Did any of this change that I am not aware of??

 

[amyjph]

The "global surgical package" is a Medicare concept (adopted by all) that "bundles" certain pre, intra and post work into a single payment with 0, 10 or 90 follow up days.

https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/globallsurgery-icn907166.pdf

You can't bill for work that would normally fall into the global just because you are out of network for a payer. The same concept applies if the patient changed insurances during the global, for example. You were paid for the surgical package so even if they changed part way through you can't then bill the new payer for post-op care. If the self-pay patient was charged a self-pay rate for the surgery which is equitable to insurance you can't charge them either. Why would they want to? Most places also have policies on this procedure. Also, with the no surprises act, this adds another piece to it. https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/no-surprises-act

I didn't look into it, but there could also be state rules regarding this.

From an ethical and compliance standpoint, it should apply to all regardless of payer (or not).

 

[thomas7331]

I agree generally. If the fees you've set for a given surgery in your practice include the postoperative care, then those fees will include post-operative care for all patients, including self-pay patients. Think of it this way, if you were a bicycle shop and when the parents paid for a bike for their child you charged one price for the whole bike, but then if an adult came in to buy a bike for themselves, you told them that the price you had on the bike didn't include the wheels, just the frame, and that wheels are an extra cost - that wouldn't be a very good type of business practice.

All that said, if a patient has no insurance, your provider can negotiate a rate as a private contract with that patient, and that can be whatever the provider and patient agree on. As a matter of good business ethics and practice, you should be transparent with the patient as to what is or is not included in the package that the provider and patient decide upon.