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Requirement to submit claims to patient's insurance for a covered service

By Daniel Staniszewski posted 03-22-2012 13:38

  
Members, I am still relatively new to MGMA, but need some assistance as to where to look for specific information.  It has become a recent issue with the dermatology practice that I oversee where patients would rather self-pay a chemical peel than have it submitted to insurance.  Obviously there are times when it is a covered vs. non-covered service - acne vs. cosmetic purposes.  I saw some old messages about this topic but did not find a specific regulation or place to look.  Any assistance would be greatly appreciated.

Thank you.
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Comments

Daniel Staniszewski
03-23-2012 16:18

Thank you Barbara, we have a consent that the patient has to sign but that is more for them stating they understand that it is a non-covered service. Yes, I am asking if it is okay to not submit a claim for a covered service. My coder for the practice believes that it is in our contract language that we have to submit a claim if it is in fact for a covered service regardless if the patient wants us to or not.

Barbara Daiker
03-22-2012 14:53

If you are asking if it is okay to not submit a claim for a covered service I don't think you will find a regulation on this. It is always the choice of the patient to not submit a claim. They have need to understand that if they change their mind laterit may not be accepted because it is outside the submission guidelines. We see this occasionally in our ophthalmology practice. You also need to be clear about prompt-pay discounts; whether or not you offer them and making sure your policy is clear and consistent.