Wiki Out of network claims, balance billing.

[JesseL]

If we send a out of network claim and "accept assignment" on box 27. Are we allow to balance bill the patient?

 

[mitchellde]

No not if you mark that you accept assignment.

 

[JesseL]

Are there any legal issues if we do not accept assignment and charge $100 to the out of network insurance when we usually charge 160 to an in-network?

We charge a lower self pay rate to patients and the patient suddenly wanted us to bill her out of network plan to reflect she paid $100 to go towards her out of network deductible.

 

[amdavis]

You can give a discount to patients if you give it to the insurance companies as well if you're billing insurance. However just be aware sometimes if you have significantly lower rates for a patient and submit it to insurance you can find yourself starting to have other insurance companies want that discount as well. What we do is usually tell a self pay patient that they can either bill their insurance or they can be self pay and have a discount. They can not have both. In Alaska we can give self pay Time of service discounts because Alaska does not care what you charge your cash patients. Unless of course your in government insurances. Your self pay discount shouldn't be less than your Medicare rates.

 

[thomas7331]

For commercial payers, I believe you can balance bill even if you're accepting assignment of benefits, accepting assignment does not create a contract that requires you to the accept the plan's rates as payment in full.

For Medicare and government payers (e.g. Medicare Advantage plans), however, you cannot - there's a law saying that if you treat the patient, it constitutes 'deemed acceptance' of the terms of the plans and you're required to follow the guidelines of the plan as far as what you can or cannot bill the patient.

 

[JesseL]

You can give a discount to patients if you give it to the insurance companies as well if you're billing insurance. However just be aware sometimes if you have significantly lower rates for a patient and submit it to insurance you can find yourself starting to have other insurance companies want that discount as well. What we do is usually tell a self pay patient that they can either bill their insurance or they can be self pay and have a discount. They can not have both. In Alaska we can give self pay Time of service discounts because Alaska does not care what you charge your cash patients. Unless of course your in government insurances. Your self pay discount shouldn't be less than your Medicare rates.

I know this is a new topic now but does that apply to out of network claims? If we were in-network they would have paid only like 67 dollars anyway. I'm still charging them more that what they would have paid if we were in-network. I really want to just have the claim reflect that the patient paid $100 since she has a out of network deductible as opposed to writing off the balance.