Wiki Self Pay versus Insurance you are contracted with

[AliMontone]

Hi,

I have just uncovered what may be an issue. I was told when I started with my new practice that the physician opted out of Medicare in 2010 (I have the opt out letter). I just received an audit letter/request from one of the insurances we are par with (Excellus BC/BS) for records on patients with their Medicare Replacement plan, stating that it is mandatory we send the records because it is part of the contract. I have a call into the provider rep, but it has not been returned yet. I pulled up the patient's charts and while I see a copy of the card in the EMR, they have made the patient's self-pay on the basis of it being a "Medicare Replacement Plan" and therefore I assume, they assumed the office was not par. These are from 2016, but I was under the impression and understanding that if you sign a contract and are par with an insurance you MUST bill the insurance company for the patient. Not make them self-pay. I am trying to find out if the physician opted out of those sections of the contract for Medicare Replacement and Medicaid Replacements, but cannot find a copy of the contract. I guess what I am asking is, if it is in the contract that we are par with their Medicare Replacement Plans, are we legally obligated to bill the insurance? Also is it illegal, to make these patients self pay? I am also thinking they are turning in their bills to the insurance afterward. Any help is much appreciated!

Ali M.

 

[thomas7331]

As I understand it, if a physician opts out of Medicare, he or she cannot be paid by a Medicare replacement plan unless it is for emergency treatment. Also, a private contract between the provider and the patient is required as part of the opt out arrangement in order to collect from the patient, so that should have been on file and would indicate that the patients understood the payment implications of the opt out. In addition, I think that prior to 2015, physicians were also required to renew opt-out status every two years, so if the affidavit is from 2010, it may not be valid. You may wish to run this all by your practice attorney before taking any further action as this could be a pretty complicated situation.

 

[AliMontone]

Thank you for the information. I have never worked for a practice that did not accept Medicare. I still haven't had a response from the provider rep, so thank you for your input!