Wiki Patients wants CMS 1500

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aangita

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QUESTION:
My question is, can a medical facility give the CMS 1500 to the patient for them to file on their own? Or does the medical provider need to file the CMS 1500 directly to the insurance company?

Background:
A patient came in and paid as cash. She used our general statement to send to the insurance carrier, and the insurance carrier wants the doctor & facility credentialing information. The patient asked that we supply her with the CMS 1500 form with that information. I told the patient we would have to file it to the insurance company ourselves. We have a global fee contract with this insurance company so we are only to use the S9083 code.

Any feedback on this would be super awesome! :eek:
 
i guess my question is "why did the patient pay cash if you are a contracted provider for her insurance?"
My understanding is this : if you are contracted with the insurance then you are obligated to file the claim for the patient. If she presented as a cash pt, and now wants a CMS-1500, that means you have to enter the charge with correct cpt and dx codes just so you can print it so you might as well file it for her. Then, we you get paid, you can reimburse what she paid you as a cash pt minus any of her responsibility of course.
Anyways, if your cash price is lower than your contracted rate, she sounds like she is pulling a fast one on you so she can actually make money on her claim. It just sounds fishy to me.

Caprice Walder, CPC
 
If a patient requests their 1500 you must give it to them, your filing with the payer is a courtesy. any provider-payer discounts will still apply when she files the claim that is why they want the provider identifing info. I often ask for my 1500s just so I can see what is being billed out, your EOB does not show you everything. It does not matter why the patient wishes to handle it this way and there is nothing fishy about it. This is why you do not give cash pay discounts!
 
No disrespect at all, but, many contracts indicate that if you are contracted then the provider must bill for the patient. This is especially true with Medicare. And - it is fishy that the patient came in as a cash patient and then requested a 1500 just so she could bill it herself. Kudos to the patients that do this just to stay on top of what is being billed, but, this situation does not appear to be that way. But hey, to each his own. Every office has their own policies that they follow.
 
Thank you all so much for your feedback. It confirmed what I already felt.

I do not know why patients who have insurance pay as cash up front, then ask for our credentialing information later to try and file it themselves. Whenever they do this, the insurance payer ends up asking us for more information anyways.

I only give patients copies of the 1500 I send to their insurer, never the originals.

Thank you both again!
 
This happens in our office. The physician will feel there is no medical necessity for a procedure and/or initially denied by insurance for covereage, but then I will sometimes receive a request from their insurance, after the patient has paid cash, because they're trying to get some type of reimbursement by appealing on their own. How do I handle this? Has anyone else experienced this? If we submit the claim, the payer then pays us, we then have to refund the patient what they've paid an accept the insurance allowed. We also, do not bill the self-pay procedures with the traditional CPT codes.
 
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