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 billing for noncovered services. You can link to each carrier’s website to obtain patient cost estimates and benefits before you provide services. Information from Cigna was not available.
Remember, you should always refer to your current provider agreement if you intend to provide noncovered services to a patient, or call the health plan if you are unsure whether a service is covered. Be sure to keep a copy of signed consent forms in the patient's medical record.
If you intend to provide a noncovered service to an Aetna member, Aetna requires that before providing the service, you (1) notify the patient that his or her insurance will not cover the service and (2) obtain the patient’s signature to a written consent statement that says he or she understands the service is not covered and agrees to pay for the service. (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, a health care provider 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 — Billing Requirements)
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’s self service resource center.
UnitedHealthcare (UHC) says you can charge UHC members for a noncovered service if you obtain the patient’s written consent, signed and dated by the patient, before providing the service. UHC says the consent must include “an estimate of the charges for that service; a statement of reason for your belief the service may not be covered; and when we determine the planned services are not covered services, a statement that we have determined the service is not covered and that the member knows our determination, and 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 Reimbursement Review and Resolution Service to help resolve insurance-related problems. Visit www.texmed.org/GetPaid for more resources and information.
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