Wiki Patient liability for not updating insurance billing changes to his account

[DLinke]

Hi!

A patient in a billing client's practice repeatedly insisted that his insurance policy hadn't changed, even though his claims were being denied because his policy had lapsed. It turned out that, while his major insurer, plan and member ID had stayed the same when he changed jobs, the third-party administrative network did change, and the card he finally produced indicated that. Unfortunately, five outpatient visit claims had gone stale by the time we received the updated information. I'm filing an appeal with the major insurer: if that appeal fails, is the patient legally responsible for paying the insurance portion of his bill for those five visits? The doctor and his practice manager think that he is, but I'd like to be sure before I rebill the patient for those charges -- especially since I believe the patient was acting out of ignorance without any intent to defraud the doctor.

Thanks for any advice you can give me!

Denise Linke

 

[thomas7331]

If the practice is contracted with the payer that was responsible for this patient's coverage during this time, then you may wish to review the contract for specifics of this situation. Most payer contracts I've seen have a clause that if the patient fails to give the information to the provider and you have documentation to show that, then the patient may be held responsible. If the practice is not contracted, then you may bill the patient, within the statute of limitations for debt collection applicable under your state's laws.

 

[JCaillouet]

If the practice is contracted with the payer that was responsible for this patient's coverage during this time, then you may wish to review the contract for specifics of this situation. Most payer contracts I've seen have a clause that if the patient fails to give the information to the provider and you have documentation to show that, then the patient may be held responsible. If the practice is not contracted, then you may bill the patient, within the statute of limitations for debt collection applicable under your state's laws.

Basically this.

I want to also address that even if the patient acted out of ignorance their policy will not take it into consideration.

The TPA changed and you're out of TFL with TPA? Unfortunate. But the visits are patient liability as the patient did not update the insurance, as long as your clause allows you to bill for PR. There are provisions in 99% of most contracts I've seen which allows for patient to be billed for services rendered.