Wiki Is it Legal to go cash pay vs bill in-network insurances?

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mystressmegs31

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I work for a Chiropractic office who wants to go cash pay on some of his therapy services such as massage therapy with or with out electric stimulation. He had asked me if it is legal to move services such as that to cash pay instead of messing with the patients insurance if he is In-Network with the insurance. So I wasn't for sure 100% on the answer and didn't want to give him a solid answer. So I wanted to reach out and ask on here as he doesn't want to get Audited and get himself in trouble. Would it be based on his contract with the insurance company on whether he can charge theses services as cash services or would he absolutely have to go through the patients insurance because he is in-network?
 
If you are in network, and are providing covered services, it would generally go against your insurance contract to force patients to pay out of pocket.
If they are non-covered services, then you may definitely charge the patient. I would advise having the patient sign something similar to a Medicare ABN before providing the service.
I don't think I have ever seen an insurance contract that would permit this, but you would have to check your contracts to be 100% sure.
A patient always has the option to opt out of billing insurance, but a contracted provider does not.
 
I agree with @csperoni. The provider's contract would almost certainly prohibit him from forcing patients to pay cash out of pocket for covered services.

If he doesn't want to bill insurance, he can terminate his contracts and be cash pay only. That may affect his volume, because there are probably patients picking him from the provider directory. However, he may decide the trade off is worth it.
 
Question:
Does anyone know if a provider is contracted as a Non Par provider with Medicare and Non Par with Maryland Medicaid, when Medicare processes their claim using the limited fees, would
Maryland Medicaid pick up the balance even though the provider is Non Par?
Does Maryland Medicaid have out of network benefits?
Thanks.
 
BRRBRR said:
Question:
Does anyone know if a provider is contracted as a Non Par provider with Medicare and Non Par with Maryland Medicaid, when Medicare processes their claim using the limited fees, would
Maryland Medicaid pick up the balance even though the provider is Non Par?
Does Maryland Medicaid have out of network benefits?
Thanks.
Click to expand...

I can't speak specifically for Maryland Medicaid, but I can tell you about Ohio Medicaid. There's a rule that the patient has to follow the rules of the primary plan.

At my former employer, there was a specific Medicare HMO that we were not contracted with. If we treated one of those patients, we would receive zero payment. Zero payment from the Medicare HMO because we were not contracted, and zero payment from Medicaid because the patient should have went to a provider that participated with their primary plan.

We tried not to accept those patients, but occasionally registration made mistakes and scheduled them for x-rays and labs. I processed a lot of write offs when that happened.

(We got paid for ER treatment, but that's it.)
 
Also, Ohio Medicaid has a tendency to not pay anything as secondary if the primary allowed amount (excluding traditional Medicare) is greater than the Medicaid allowed amount. So it's incredibly rare that we see secondary Medicaid payments for most of our patients.
 
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