Wiki Credentialing & Billing

[kmleland]

Good Afternoon. I'm hoping for some help. I work for a third party billing company & I have a client that I bill for that does not want to take Aetna, Cigna, Humana or Molina anymore because he feels they don't pay enough. He has told patients with these insurances that they must be self pay because the office doesn't take their insurance.
If he still has an active contract with any of the payers above, isn't he required to bill the insurance unless the patient requests that we don't?
Thanks!

 

[thomas7331]

Yes, most payer contracts would not allow a provider to do this - if he hasn't terminated his agreements with the payers, he likely is putting himself in breach of his contract. You'd have to look at each of his contracts and the specifics to know more.

It's usually a really simple process to terminate a contract though - often a 60-day or 90-day notification is all that's required. He should just bite the bullet, go through the termination process and be done with it, and not put himself at risk of getting sued. You might want to let him know too that payers often have shortages of providers and need to keep them in their networks, and if that's the case, when they receive a notice to terminate it can sometimes open the door to negotiating a better compensation arrangement.