Wiki Provider is in-network with insurance but collecting Private Pay.

[JedecMS]

I am working for a provider who is contracted with certain insurances but is now having me collect full payment from patients and then giving them a superbill to have them send into their insurance. But is fully contracted with these insurances at an allowed amount. Can he do this?? I thought he could only take the allowed amount??

 

[sls314]

I am working for a provider who is contracted with certain insurances but is now having me collect full payment from patients and then giving them a superbill to have them send into their insurance. But is fully contracted with these insurances at an allowed amount. Can he do this?? I thought he could only take the allowed amount??

If he has an in-network contract with that insurance company, he's almost certainly in violation of it. I've read and negotiated a lot of managed care contracts, and here are some examples of typical contract clauses that he'd be violating:

1) His contract would have agreed to in-network rates. If he's charging the patients full billed charges, that's a contract violation.

2) His contract most likely has provisions about submitting claims to the insurer on behalf of the patients.

Additionally, the insurer will send payments to in-network providers. He is going to have a LOT of angry patients demanding refunds after the patient finds out that both they and the insurer paid the provider for the same service. (If I were one of those patients, I'd file a complaint to my insurer and every regulating board I could.)

If he wants to do business like a non-contracted provider, then he needs to BE a non-contracted provider. He can give notice and terminate his contract.

(There will be a notice period where he'll still have to bill the claims until his official termination date. His contract will spell out what he needs to do to terminate the agreement and how long his notice period will be.)

 

[csperoni]

Susan is right on the nose. Your participating provider contract prohibits you from collecting from patient beyond in network deductible/copay/co-insurance. If the provider is not pleased with the network contracted rates, you may TRY to negotiate (do not necessarily expect results on this), or terminate the contract. Usually there is a time period of 60-90 days from notice until actual termination. Once the provider is out of network, you may then charge commercial patients your full rate. Opting out of Medicare is possible, but you must follow all the correct notification steps.

 

[JedecMS]

If he has an in-network contract with that insurance company, he's almost certainly in violation of it. I've read and negotiated a lot of managed care contracts, and here are some examples of typical contract clauses that he'd be violating:

1) His contract would have agreed to in-network rates. If he's charging the patients full billed charges, that's a contract violation.

2) His contract most likely has provisions about submitting claims to the insurer on behalf of the patients.

Additionally, the insurer will send payments to in-network providers. He is going to have a LOT of angry patients demanding refunds after the patient finds out that both they and the insurer paid the provider for the same service. (If I were one of those patients, I'd file a complaint to my insurer and every regulating board I could.)

If he wants to do business like a non-contracted provider, then he needs to BE a non-contracted provider. He can give notice and terminate his contract.

(There will be a notice period where he'll still have to bill the claims until his official termination date. His contract will spell out what he needs to do to terminate the agreement and how long his notice period will be.)

That is what I thought. I tried to tell him this but he said he can do what he wants as a provider. We have other patients that we bill insurance for so he wants to still be in contracted with them but for new patients he wants to tell them we don’t take insurance anymore, that they can pay for the visit and then send in a claim themselves, he says tell them it is not a guarantee of full payment. Some patients are being referred to us and don’t understand why they have to pay upfront. I’m not sure what I should do. I don’t fell comfortable with this.