Wiki Can Insurance be billed if patient received a discount

[mrumbo]

Our specialty office is a self pay office/out of network provider. Patients are required to pay for services up front and we will courtesy bill for them if they have any insurance coverage. If the patient receives a discount on the services can we still courtesy bill the insurance for the patient for the discount amount?

 

[candle99]

Our specialty office is a self pay office/out of network provider. Patients are required to pay for services up front and we will courtesy bill for them if they have any insurance coverage. If the patient receives a discount on the services can we still courtesy bill the insurance for the patient for the discount amount?

I am not an expert on the subject at all but I believe discounts could be an issue. I would have several questions when discussing discounts.

1. What is the customary office fee for the visit/service provided to the patient?
2. Where is the usual and customary fee documented?
3. Does the office have an official policy regarding discounts?
4. Are the discounts being arbitrarily enforced or applied consistently?
5. Are the discounts based on household income or some other criteria?
6. Is the discount simply a waiver of responsibility for copays or deductibles?
7. Is the insurer being billed at a higher rate than the usual and customary fee for the service?

 

[thomas7331]

The amount you bill on a claim should always be the amount your practice is willing to accept as payment in full. It can be considered a false claim if you are billing one amount on a claim but accepting a different amount from the patient. Also, it's important to keep in mind that if you've discounted your bill to one amount but bill a higher amount to the insurance company, that it will cause the insurance company to incorrectly calculate the patient responsibility. For example, they could apply the full amount toward the patient's deductible when the patient has not actually spend that much for the deductible. This would be the equivalent of giving the patient a financial reward or inducement for seeing your provider, which is some case may not be legal. On another note, be very cautious about making patient self pay if they are covered by government programs or are a part of a managed Medicare or Medicaid plan - even if you are out of network, you may be required to comply with the terms of those plans. To avoid problems, practices should create a policy and procedure for patients discounts and have it reviewed by a lawyer to ensure that it is compliant with all laws.