This is a question commonly asked by many practices, and it is a loaded question! The answer is: It Depends.
Depends on what? There are as many rules surrounding what you can and cannot bill a patient for as there are for sending clean claims. I will try to de-mystify the most common scenarios here.
True patient responsibility falls first from the plan itself. There are some issues you really cannot fix, despite your best intentions. These are: Coordination of Benefits, Pre-existing Conditions, and Excluded Services. If a claim is denied or pended for any of these reasons, the only person that can remedy the situation is the patient. It IS their plan after all, they purchased it, and they are responsible for the terms under which it is administered.
The recommended action for these issues is to advise the patient of the situation and provide them with the steps they need to follow, such as contacting their insurance company, agent, or HR department for further instructions. Advise them that they will continue to be responsible for the bill until the issue is resolved.
The next type of patient responsibility has slightly more complex rules.
Incorrect or Termed Policy – Termed policies sound black and white, but there are some steps needing to be followed to ascertain if you should be going after the patient. Remember, it is always the patient’s responsibility to present the correct insurance at the time of service. You should first see if this was done or if the error stemmed from anyone that touched the claim downstream. When that is the case, the patient is not liable. If the patient did not present the correct insurance, then the patient is liable to correct that error or to pay for the claim. It’s as simple as that, right?
Experimental and Investigational – This is a situation where a recommended treatment is not covered by the payer. It is ok to hold the patient liable for these treatments, but only if the patient was informed beforehand, and there is a signed agreement to that effect. Most provider/payer contracts include language to that this protocol will be followed, or the patient will be held harmless. The language may be in the contract, or more likely the contract will reference the provider manual, which is where this rule (among many others) will be found. Regardless, your PR is best if your patients are not surprised.
Then you have denials that absolutely cannot be transferred to your patients. They are:
No Authorization – It is the practice’s responsibility to obtain prior-authorization for treatments that require it. If an auth was not obtained, or was exceeded in any way, you cannot bill the patient. It is unfortunately the practice’s liability, and the practice that will pay in the end.
Not Medically Necessary – Like Experimental listed above, if a treatment is presented to a patient as covered by their insurance, but upon review the chart does not meet the guidelines set forth by the payer, you would not be able to hold the patient liable unless they were informed ahead of time. By informed, I don’t mean the generic financial terminology that all practices have the patient sign stating that they will pay for any services that are denied for any reason. This sounds great, but wouldn’t hold up in court. Holding a patient responsible for the provider’s bad charting is bad press! If there is any chance the treatment may not meet the insurance guidelines, be specific and discuss this with the patient first, and…. Always get it in writing!
Last but not least, there is Medicare.
If a treatment is considered non-covered by Medicare, and the patient is willing to pay cash, you must get an ABN signed, for each treatment. This has to be retained in the patient’s chart, and made available to Medicare if requested. If you don’t have it, then you have to write it off. If you have never heard of an ABN, here is a link to download one. https://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.html Some examples of when to get an ABN signed is: for compression stockings, for cosmetic sclerotherapy, for diagnostic imaging that doesn’t meet the LCD, or for treatment when they refuse to do conservative therapy.
Knowing when you can bill a patient is an important part of the well-managed practice. As the insurance carriers shift more of the burden to the provider it is critical to collect every dollar possible.
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