Out of network vs. in network benefits (Full Version)

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yarringtonpt -> Out of network vs. in network benefits (December 18, 2006 6:20:00 AM)

Scenario:

I am out of network with insurance company A. Their out of network PT benefits are 70% after a $1000 deductible is met.

Their in-network benefits are a $20 co-pay per visit and 100% coverage, no dedutible.

Is it legal for me to just accept a $20 "co-pay" from her.

Should I just establish an agreed upon privatge pay rate?

Thanks,

Eric



SJBird55 -> Re: Out of network vs. in network benefits (December 18, 2006 6:28:00 AM)

So, how are you billing her for services? You are out of network... you can send a claim for the patient to the insurance company. If you send a claim to the insurance company, how will you be paid? Generally, if non-participating, then the insurance company will cut a check to the patient. If there is a $1,000 deductible and a 70% co-pay, then it is probably highly unlikely that the patient WILL receive a check from their insurance company, but the insurance company will be tracking the $1,000 until that amount is reached to then begin paying only 30% of the claims that you send. If you only accept the $20 copay, from her and being out of network, that is all that you are going to receive which isn't reasonable from a business view nor from the insurance contract she has with her insurance company.

If she doesn't plan on using many out-of-network services, it would probably be a better deal for her to just private pay on a fee schedule that she negotiates with you. If she did that, then she shouldn't send in anything to her insurance company, but for tax purposes, if she itemizes, she can keep her receipts. Her out of network savings are so minimal, that it would make better sense to just negotiate with you and pay out of pocket - unless, of course, she'd prefer to go in network and pay $20 per visit.



yarringtonpt -> Re: Out of network vs. in network benefits (December 18, 2006 6:48:00 AM)

SJBird55:

Is it legal to negotiate a private-pay fee schedule or flat rate if I am contracted with Medicare and others? Can I charge less than Medicare pays?

Thanks,

Eric



SJBird55 -> Re: Out of network vs. in network benefits (December 18, 2006 8:44:00 AM)

I negotiate with patients. If you think about it, when you sign a contract to be considered a "participating" provider, you are agreeing to the fee schedule the insurance company has and you are agreeing that you will accept that fee schedule. Every insurance company has a different fee schedule. If you participate with Medicare, then according to that contract, you technically cannot have a fee schedule with anyone that is less than Medicare's fee schedule.

I have patient's negotiate with me and sign a contract as to the fee schedule he/she agrees to pay. The fee schedule that they agree to is slightly greater than Medicare's because I do participate with Medicare.

Every patient that I treat is charged the same darn fee schedule. What is charged is always equal. So, if you were to look into my computer ledger thing, "charged amount" no matter who the patient is or who the payor is will always be consisten. What I am paid for services is dependent upon what was negotiated between the payor and myself. Some pay more; some pay less. So, if you were to look into my computer ledger thing, "expected amount" will vary depending upon the contractual agreements. None of them pay less than what Medicare pays though. I have not signed an agreement with any payor or person in which my services are paid at values less than Medicare's fee schedule. That was a business decision that I made and I refuse to accept less for the services that I provide.

If you were to do the flat rate thing, which was the way BCBSM paid prior to October 2006, I would make sure that you charge the patient the same as you would anyone else. As you charge the CPT codes, the cost of those units is basically added up until you reach the agreed upon maximum amount you'd accept per visit. Basically, with a flat rate thing, you have decided to accept a contract in which you are capped in the amount of money you will be able to make for the services that you provide. I would assume that it is definitely legal to negotiate a flat rate because this whole year in MI, I had no other options when being a participating provider for BCBSM.

Hopefully all that makes sense.



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