Wiki Insurance and Self Pay

[JCaillouet]

My apologies for bringing this up if having been addressed before:

Patient has insurance. Chooses to go for 'self pay' rate/no insurance.

Third party vendor discovers patient had insurance.

Patient paid the discounted rate. Do we 'bill' the insurance even if patient did not request the visit to be sent to their insurance?

 

[thomas7331]

I don't think you can legally bill the patient's insurance without their consent. But I may not be understanding the scenario you're describing. Under what circumstances would a 'third party vendor' gain access to a patient's records and identify that they in fact had insurance if the patient had paid for the service?

 

[junebug3860]

Retired medical biller (20+ years)

The patient/guarantor for a minor must give permission to bill an insurance carrier on HCFA 1500 claim form boxes 12 and 13. See link:
http://www.nucc.org/images/stories/PDF/1500_claim_form_instruction_manual_2012_02-v6.pdf

In my years of billing, if a patient does not want the service submitted to the insurance, they have a reason for it. For example, sometimes they don't want the dx to go on file anywhere.

June Grimmette CPC-A
Retired from Michigan Medicine (U of M Health System)

 

[JCaillouet]

Let me clarify.

We have patients who identify as self insurance.

We have a third party which runs the self pay patients, especially those with outstanding balances, through a system to see if they qualify for Insurance (E.G. Medicare, Medicaid, Commercial)

We discover patient has insurance. Do we bill claim to insurance?

 

[DeBillingTater]

No, in any circumstance, you do not bill the claim to insurance without the patient's consent. Regardless of their insurance status.

 

[thomas7331]

I think this is really a legal question and not one that is easy to answer without knowing all of the facts involved, and as such should be answered by your practice's attorney or compliance officer. As I'm sure you're aware, there are compliance implications involved with any kind of disclosure of protected patient information with outside entities. It may be possible for you to bill insurance if the patient has given proper consent at the time of treatment and if your privacy policies have appropriately notified the patient that you may do this in the event of an unpaid balance. But I would recommend asking your manager or legal advisors who are familiar with your practice's documents, policies, and the applicable regulations in your area, to validate whether or not this is appropriate.