Can you charge a patient for a service the patient’s health insurance plan doesn’t cover? Answer: It depends.
TMA’s reimbursement specialists collected the top carriers’ policies on noncovered services (see below). You may link to each carrier’s website (listed below) to obtain patient cost estimates and benefits before you provide services. Information from Cigna was not available.
Aetna says you should refer to your provider agreement if you intend to provide noncovered services to a patient who is an Aetna member. Look for information about your obligations to “(1) inform the member that the services will not be covered and (2) obtain member’s prior consent in writing to pay for the specified services.” (Aetna’s office manual)
To obtain patient cost estimates and benefits, see the Aetna Payment Estimator.
Blue Cross and Blue Shield of Texas (BCBSTX) says in the event it “determines in advance that a proposed service is not a covered service, the [physician] must inform the subscriber in writing in advance of the service rendered. The subscriber must acknowledge this disclosure in writing and agree to accept the stated service as a noncovered service billable directly to the subscriber. (Blue Choice PPO Provider Manual — Filing Claims)
To obtain patient cost estimates and benefits, see the BCBSTX Patient Cost Estimator.
Humana says physicians may not “bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against any Humana Member, subscriber, or enrollee other than for copayments, deductibles, coinsurance, other fees that are the Member’s responsibility under the terms of their benefit Plan, or fees for non-Covered Services furnished on a fee-for-service basis.”
Noncovered services are those not covered by Medicare, or services excluded in the patient’s benefit plan. (Humana’s provider manual)
To obtain patient cost estimates and benefits, visit Humana Provider Self-Service Online.
UnitedHealthcare (UHC) says you can charge patients who are UHC members for a noncovered service if you obtain the patient’s written consent, signed and dated by the patient, before rendering the service. Keep a copy of the consent in the patient’s medical record. In addition, UHC says: “If you know, or have reason to suspect, the service may not be covered … the written consent also must include: (a) an estimate of the charges for that service; (b) a statement of reason for your belief the service may not be covered; and (c) in the case of a determination by us planned services are not covered services, a statement that we have determined the service is not covered and that the member, with knowledge of our determination, agrees to be responsible for those charges.” (UHC’s administrative guide)
To obtain patient cost estimates and benefits, see the UnitedHealthcare Claim Estimator.
If you have questions about billing or payer policies, contact TMA’s reimbursement specialists for help at paymentadvocacy[at]texmed[dot]org, or call the TMA Knowledge Center at (800) 880-7955. TMA members can use the TMA Hassle Factor Log to help resolve insurance-related problems. Visit www.texmed.org/GetPaid for more resources and information.
Published April 13, 2017
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