Ask the AMBA Expert – Medical Billers Answer Billing Questions, websites that answer questions.#Websites


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AMBA Members Answer Your Billing Questions

Q: Can I charge no-show patients a fee for missed appointments?

A: You may be glad to know that Medicare has finally addressed what you must do in order to bill patients for no shows.

Previously, each Part B office had their own requirements regarding charging Medicare patients for missed appointments. TRICARE (TriWest Healthcare

Alliance) regulations required providers to establish office practice policies regarding no show fees and required beneficiaries to sign an agreement taking financial responsibility for missed appointments. Other offices like WPS Medicare only required that provider also charge non-Medicare patients for no shows, too.

Information provided by Cyndee Weston, Executive Director, AMBA

Q: Must I provide a copy of patient records to a patient if they owe a balance?

A: Yes, providers must provide copies of patient medical records to any patient that requests them regardless of if they have a balance due in the office, although you may charge a reasonable fee for copying the records and time for staff to complete the request.

We encourage all providers to review the answers to questions like these at their state board websites, as different states have different laws and requirements. Interpretation of the law is usually not provided by state board staff so if in doubt ask your own attorney to interpret the law for you.

For example, patients will often assume that x-rays are part of their medical records that they have the right to take. Providers are responsible for keeping the original x-rays or records for the length of time specified by their state board and/or HIPAA. What the patient IS entitled to is the information contained within those particular records/x-rays. Providers should offer patients a copy of the x-rays, which can be charged to the patient, or a report of the findings in that x-ray but not release original x-rays to patients.

If a patient needs the x-rays for an appointment with another provider, recommend that they have the new provider send a request for release of x-rays to your office. Providers are better releasing the x-rays to another physician because then this provider becomes responsible for the original and will most likely return them to the original providers office for proper record keeping. Most patients don’t bring back the originals and providers could jeopardize themselves by releasing original x-rays to the patient.

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Q: What is MultiPlan and why are they asking me to take a greater discount?

A: There are 3 products that MultiPlan offers.

You can find a breakdown of the 3 products below that MultiPlan offers at http://www.multiplan.com/solutions/

1) Primary PPO Network — primary PPO network access under the PHCS Network and HealthEOS by MultiPlan (HealthEOS in Wisconsin only)

This is a PPO network in the true sense of the word. If you are already a participating provider with PHCS, then according to MultiPlan customer service dep’t, you will need to recredential through MultiPlan. You may download the credentialing forms at: http://www.multiplan.com/providers/howtowork/credentialingforms.cfm

If you are already credentialed with MultiPlan on the Primary PPO Network, your claims will be processed as an “in-network” participating provider at the contracted rate. Patients will be responsible for the “in-network” copay or coinsurance and deductible.

2) Complementary Network — The MultiPlan Network adds to the coverage of a primary PPO or HMO/POS/EPO by giving health plan participants an additional choice of providers at discounted rates. When participants seek care outside their primary network, they typically pay a higher coinsurance rate but share in the savings achieved by the network discount. In provider terms, this means that you will be accepting a discounted rate for your services but you will still be considered an “out-of-network”, non-participating provider. Your patients will still be responsible for the “out-of-network” copay, coinsurance, and deductibles which are typically higher than “in-network” on most plans.

Example of how out of network claims would process if you are not a member of the Complimentary Network as opposed to being a member. Keep in mind that there are many, many, variables in insurance plans, but the following is a basic example:

Non-Member —your billed charge for a visit is $100. The patient’s out-of-network deductible has been satisified. The patient has an out-of-network coinsurance of 30% (as opposed to an in-net copay of $15). You will charge the patient $30 in the office for his coinsurance and submit the bill for $100. The insurance carrier processes the claim at the out of network rate. You receive a check for $70 (the out of network reimbursement of 70%). When all is said and done, you have received 100% of your usual and customary charges, or $100.

Now, same scenario, but the patient’s out-of-network deductible has not been satisfied. The patient must pay the entire $100 for services rendered and the entire $100 is applied to the patient deductible. Again, you have received 100% reimbursement for your usual and customary charge.

Member of the Complimentary Network— your billed charge for the visit is $100. You have agreed to accept a reduced rate of $65 for the visit. The patient’s coinsurance amount is now $19.50 as opposed to $30. A savings for the patient, but still more than his in-network copay of $15. You then submit your claim for $100. The insurance carrier automatically reduces your bill to $65. Now they pay you 70% of the reduced amount, or $45.50. You have received a total of $65 for the visit.

Now, same scenario, but the patient’s out-of-network deductible has not been satisfied. The patient must pay the entire $65 towards his out-of-net deductible at the time of service. You submit your claim for $100. $65 is applied to the patient’s deductible. You have received a total of $65 for the visit. However, because only $65 was applied to the out-of-net deductible, instead of the full $100, it will take the patient longer to satisfy that deductible. This may be a concern for providers who treat patients over the course of many visits.

3) Fee Negotiation— this is the 3 rd product that MultiPlan offers. MultiPlan

has negotiators working individually with non-contracted providers to reduce the cost of their claims. Typically an offer will come to your clinic via fax requesting that you either accept or reject an offer to reduce your charges. It is usually titled Expedited Fee Negotiation Agreement and requests that the provider accept the “expedited price”, less any out-of-network coinsurance and deductibles, for a specific patient visit. It may also state that upon receipt of the signed agreement, your claim will be processed and payment issued within 10 days.

Keep in mind that many of the larger carriers will process and pay a clean electronic claim in 14 days, therefore you may not actually get paid any faster than you would if you rejected the offer and stand by your usual and customary charges.

According to MultiPlan’s customer service dep’t, a provider may enroll in the Primary PPO product for PHCS plans and exercise the option to not enroll in the Complimentary Network for plans in which he or she is out-of-network. Be sure to read all portions of the application to be certain that you are enrolling only in the products that you want.

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Q: Can I bill a patient that hasn’t been seen in two years as a new patient?


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