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Miscellaneous Insurance/Billing Q's - Billing under another doc's name/Fee negotiation/Different Docs, Different rates?

December 20, 2012

Billing under another doc's name

Question:

Jennifer,
 
If a patient comes to see a doctor in the practice, with a referral, but that physician has to leave on an emergency, can another non-referred doc see that patient and bill the visit under original doc?

Thanks,
Dr. P

Answer:

As I interpret this question, whether billing is performed under the referred doctor and the provider of services is identified as the referred doctor, when in fact another doctor in the group, not the referring doctor, performed the service is appropriate, the answer is absolutely not.  Failing to appropriately identify the treating provider on the billing, medical record or otherwise will create a heap of potential trouble from payors, regulatory agencies, etc.  Do not do this. 


Fee negotiation

Question:

Jennifer,
 
Are there ramifications of accepting or not accepting the offered 25% discounted pay acceptance for out of network care?  The insurance companies promise quicker payment, not even sure why they can do this and we can't do the same.


Thanks,
Dr. P

Answer:

The offer for a reduced fee and quicker turn around is a negotiated compensation arrangement between two parties and has been opined to be appropriate.  The availability of this option for an insurer is grounded in contract law - there is an offer and an acceptance.  The ramifications are that  you are accepting final payment for the service. Now, accepting the insurer's reduced amount will not mitigate your responsibility to balance bill the patient for the full amount billed if that obligation exists for a particular service based on your par/non-par status.  As for a doctor's practice not authorized to negotiate with patients for a fee or vice versa, a doctor is required to make a good faith effort to collect the total fee owed, because that fee is what has been presented for reimbursement (presumably) to an insurer.  If after the good faith effort has been expended, under certain circumstances the practice would be entitled to negotiate a reduced fee.  Why the carrier has the ability to negotiate in the initial instance is due to the fact that the carrier is a party to the reimbursement contract with the patient.  Also, negotiating with payors by practices is also allowed, although of course not an even playing field.  Wish I had better news!

Different Docs, Different rates?

Question:

Jennifer,

Why is it legal for insurance companies to pay different surgeons or facilities different rates for the same CPT codes?  Is it possible for a 2 person group negotiate higher rates when most surgeons in the area are full time with a large institution and get a significantly higher rate when the hospital bills for them.

Thanks,
Dr. P

Answer:

Fees with insurance companies are contractual.  Absolutely you can attempt to negotiate better rates.  You may also want to check out whether there is a local IPA (Independent Practice Association) or ACO (Accountable Care Organization) in your area, or other network, that you may join and participate in their higher reimbursement rates.


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