MonarchMedBill
Guest
There are 2 sides to my question:
1.) Recently I came across a patient that was seen in our office for a specialist follow up visit. The patient's insurance (BCBSTX) requires a referral from the PCP. The PCP on file was contacted but stated he is not the patient's PCP, has only seen the patient once and would not give us the referral. The patient's daughter confirmed that is who her mother states is the PCP. The patient has been seen 3 times in our office and each time paid a $40 copay. The claims have all been denied for no referral. We billed $360.00 for each visit, collected the $40 copay and then when the claim was denied the remaining $320 was adjusted off as not payable since we didn't obtain a referral. The office kept the $40 as payment for services. The office offers a discount to cash pay patients making office visits $60. The reps that worked this claim before I came on board (2 months ago) accepted the $40 as payment in full - stating it wasn't the patients fault that a referral wasn't obtained. I confirmed with a rep that the PT's plan only requires the $40 copay for the PCP visit. Specialist visits have no copay but are subject to 70% coinsurance of allowed amount.
I believe in this case, we are required to refund the patient the $120 she has paid in copay amounts. We can't bill the patient for coins or deductible since the claim was denied. Is there any documentation from a legal standpoint that I can use to prove this to my employer?
2.) In the notes I read that the plan is to let the patient know if we cannot obtain a referral from her PCP, she will have to be a cash pay patient and we will bill her $60 for all future visits. This patient is subject to deductible and coinsurance responsibilities within her BCBSTX contract. I am finding mixed reviews on letting insured patients pay cash. I've read it is okay to bill the patient cash as long as we bill her the same thing we would bill the insurance - and that we can't offer her a discount if we don't offer them one. I've read that we are required to submit the claim to the insurance and let them know how much she paid at the time of visit. Either way I can't find anything from a reliable source to use for documentation.
HELP!
1.) Recently I came across a patient that was seen in our office for a specialist follow up visit. The patient's insurance (BCBSTX) requires a referral from the PCP. The PCP on file was contacted but stated he is not the patient's PCP, has only seen the patient once and would not give us the referral. The patient's daughter confirmed that is who her mother states is the PCP. The patient has been seen 3 times in our office and each time paid a $40 copay. The claims have all been denied for no referral. We billed $360.00 for each visit, collected the $40 copay and then when the claim was denied the remaining $320 was adjusted off as not payable since we didn't obtain a referral. The office kept the $40 as payment for services. The office offers a discount to cash pay patients making office visits $60. The reps that worked this claim before I came on board (2 months ago) accepted the $40 as payment in full - stating it wasn't the patients fault that a referral wasn't obtained. I confirmed with a rep that the PT's plan only requires the $40 copay for the PCP visit. Specialist visits have no copay but are subject to 70% coinsurance of allowed amount.
I believe in this case, we are required to refund the patient the $120 she has paid in copay amounts. We can't bill the patient for coins or deductible since the claim was denied. Is there any documentation from a legal standpoint that I can use to prove this to my employer?
2.) In the notes I read that the plan is to let the patient know if we cannot obtain a referral from her PCP, she will have to be a cash pay patient and we will bill her $60 for all future visits. This patient is subject to deductible and coinsurance responsibilities within her BCBSTX contract. I am finding mixed reviews on letting insured patients pay cash. I've read it is okay to bill the patient cash as long as we bill her the same thing we would bill the insurance - and that we can't offer her a discount if we don't offer them one. I've read that we are required to submit the claim to the insurance and let them know how much she paid at the time of visit. Either way I can't find anything from a reliable source to use for documentation.
HELP!