Wiki Provider Payer Enrollment Question

[tdfaircloth]

I work for a Medical Billing Company in West Tennessee. We have client's whose providers are not enrolled with some payers (Medicaids, Blue Cross, Cigna, Aetna, UHC) but these providers still see patients with plans they are not enrolled with. The client's insist that we send claims for the unenrolled plans although we probably will not receive any reimbursement for these claims.

We have Enrollment edits in place that will not allow a claim to drop if the provider is not enrolled.

I would like to know how others are handling claim submission to payers that their providers are not enrolled with. Do you drop a claim, write off, etc?

Thanks,
TFaircloth

 

[elysia.york]

File

In every practice that I have ever worked with, there has always been many cases where the provider was not enrolled with a policy. When we encountered that, the receptionists usually told the patient up front, and we would let them know the likelihood that their claim would get denied and they would owe the whole visit. It was then up to the patient whether or not they were going to be seen. If they chose to be seen, we would have the patient pay half of their visit up front and file as normal.

However, in your case...where you are just a billing company with no patient contact, I would just file the claim. The services were rendered, therefore the patient is responsible if their insurance does not pay.

Hope this helps.

Elysia York, CPC
Rheumatology Services Coordinator - Dothan Medical Associates, PC