Q/A: How Do I Respond to a Patient's Request to Not Submit the Claim to Their Insurance?

May 7th, 2018 - Wyn Staheli, Director of Research
Categories:   Chiropractic   Billing   Compliance   HIPAA|PHI  
0 Votes - Sign in to vote or comment.

Question

A number of patients now have high deductible plans. Sometimes, deductibles can be $5000 or $10,000. My payer contract states that I must submit all claims to insurance for covered services. However, sometimes patients with these high deductibles come to my office and state that they would prefer to receive a modest discount for paying cash and in turn, not have their services submitted to insurance. As a doctor, this places me in a tough situation. Do I follow the patient's wishes or the payer contract?

Answer

HIPAA's "Out of Pocket” provision allows a way for you to honor your patient's wishes. However, ALL of the following criteria must be met:

  1. The patient completes a "Request to Restrict" disclosure form
  2. The disclosure is to a health plan for payment or health care operations
  3. The disclosure is not required by law (e.g., court ordered)
  4. The protected health information pertains solely to healthcare for which the patient (or someone on behalf of the patient) has paid for in full out of pocket (partial payments do NOT count)

As a provider, you must ensure that you have that patient encounter information flagged or tagged differently than other patient encounters to avoid an inadvertent disclosure to their insurance which would be a HIPAA violation.

Be sure that the patient understands that they CANNOT come back and ask you to submit the claim to the insurance AFTER the fact.

Note: Be sure your HIPAA Notice of Privacy Practices specifies that they have this option.

The appropriate disclosure form (Patient Request(s) Regarding Healthcare Records) is part of the HIPAA Compliance product and can be downloaded after purchase.

ALERT: For more information about high deductibles, cash plans, fee schedules and more, there's a webinar tomorrow. CLICK HERE to register.

###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

Eliminating Consultation Codes?
October 10th, 2019 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
There are a few payers that have joined with CMS in discontinuing payment for consultation codes. Most recently, Cigna stated that, as of October 19, 2019, they will implement a new policy to deny the following consultation codes: 99241, 99242, 99243, 99244, 99245, 99251, 99252, 99253, 99254 and 99255. United Healthcare announced they ...
Hypertension & ICD-10
October 7th, 2019 - Raquel Shumway
Hypertensive Diseases and ICD-10. Helps and examples for these codes.
CMS and HHS Tighten Enrollment Rules and Increase Penalties
October 1st, 2019 - Wyn Staheli, Director of Research
This ruling impacts what providers and suppliers are required to disclose to be considered eligible to participate in Medicare, Medicaid, and Children's Health Insurance Program (CHIP). The original proposed rule came out in 2016 and this final rule will go into effect on November 4, 2019. There have been known problems ...
Federal Workers Compensation Information
October 1st, 2019 - Wyn Staheli, Director of Research
When federal employees sustain work-related injuries, it does not go through state workers compensation insurance. You must be an enrolled provider to provide services or supplies. The following are some recommended links for additional information about this program. Division of Federal Employees' Compensation (DFEC) website Division of Federal Employees' Compensation (DFEC) provider ...
2020 Official ICD-10-CM Coding Guideline Changes Are Here!
October 1st, 2019 - Wyn Staheli, Director of Research
It’s that time of year for offices to get ready for the ICD-10-CM code revisions. As part of that process, it’s also good to know what is going on with the ICD-10-CM Official Guidelines for Coding and Reporting. In the examples listed below, strikeout text is deleted and highlighted text ...
The New ICD-10-CM Code Updates Are Here — Are You Ready?
October 1st, 2019 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99) A small revision in the description changed[STEC] to (STEC) for B96.21, B96.22, B96.23. Remember, in the instructional guidelines, ( ) parentheses enclose supplementary words not included in the description (or not) and [ ] brackets enclose synonyms, alternative wording, or explanatory phrases. Chapter 2: ...
New Codes for Dry Needling
September 30th, 2019 - Wyn Staheli, Director of Research
Find out what you need to know about the new codes for dry needling, also known as trigger point acupuncture.



About Codapedia by InnoviHealth Systems Contact Us Terms of Use Privacy Policy Advertise with Us

Codapedia™ by InnoviHealth Systems™ - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain) - Fax (801) 770-4428

Copyright © 2009-2019 Find A Code, LLC - CPT® copyright American Medical Association