Provided by:  Jennifer Kirschenbaum, Esq.

May 21, 2019

 

Question


Hi Jennifer,

As a cosmetic provider, I am in network for insurances. However, across the board, we do not accept any NEW patients under any insurance only based care. When patients are having cosmetic services, we are willing to submit to insurance for those services that could potentially be covered rather than charge them for these services, but they are primarily cosmetic patients.

If I do see a patient for something that could potentially be covered (like a broken nose), we tell them before the visit that we are not accepting new patients and will charge a cosmetic fee for the service. We will then provide them with any information that they need in order to submit on their own behalf. This is identical to an out of network provider. The only difference is that I am in network but not accepting new patients.

Does this make sense?  Is this an okay practice? 

Thanks, Dr. K 




Answer

This is a tough out-of-pocket question to answer because I have not reviewed your third party payor contracts.  But, assuming same read like the standard lot, any patient you see that is an insured for an carrier you contractually participate with, at a location you have agreed ot accept such insurance, is required to be treated and billing in accordance with your payor contract.   So, what you describe above may constitute breach of contract.  No one may be the wiser, ever, or you have a patient complain for disparate treatment and you could have a real issue.   You may want to check out your contracts...

Also of note - you make a point about cosmetic - regardless your in network patients and status likely would not qualify for reimbursement by insurance for the cosmetic procedures - which would allow (again, potentially pursuant to contractual restrictions - so have to check) for fee-for-service direct patient pay.  
 


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