Wiki How do you bill for non-covered services?

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AlexanderF

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Hello,

I am new here and think my question may sound very basic.

Can we bill the patient for services not covered by their payer or denied by their payer (commercial insurance or Medicare)? Specifically, I saw a patient in my clinic (outpatient private practice) with Cigna PPO insurance (we are in-network providers). I performed trigger points injection (CPT 20553) and used ultrasound guidance for needle placement (CPT 76942). The CPT 20553 was reimbursed, yet the CPT 76942 was not because it was "Not Covered or Reimbursable when used for guidance with trigger point injections", as per Cigna Medical Coverage Policy. Can I bill the patient for the ultrasound guidance? Would that violate an agreement with Cigna (or any other payers, Medicare) when we became in-network providers? How do I do it properly (having the patient sign a financial consent or any other form?). Does the reason for not coverage matter (not medically necessary, experimental, not-covered service, etc)?
 
In this case you cannot bill the patient. Insurance companies have medical policies that specify what they will cover. I believe Cigna does have a policy on trigger point injections that states guidance is not covered. Because you are contracted with an insurance company does not mean they will reimburse for all services. It is beneficial to research their medical policies. Also, if an insurance company states no prior authorization is required, I would definitely look for a medical policy on the service as there is most likely certain criteria that has to be met for the service to be covered.
 
Got it! Thank you! But what I am curious is, why can't we bill the patient the fee for the service we provided that the insurance does not cover? Insurance may not consider certain medical services necessary or simply experimental/not covered by the policy, but that doesn't mean these procedures can not be performed if clinically indicated. For example, some payers do not cover occipital nerve blocks (while others do). If the occipital nerve block is not covered, we can still do it, and the patient will pay whatever the cash fee might be (as long as we inform the patient about the cost ahead of time). Am I wrong?
 
AlexanderF said:
Got it! Thank you! But what I am curious is, why can't we bill the patient the fee for the service we provided that the insurance does not cover? Insurance may not consider certain medical services necessary or simply experimental/not covered by the policy, but that doesn't mean these procedures can not be performed if clinically indicated. For example, some payers do not cover occipital nerve blocks (while others do). If the occipital nerve block is not covered, we can still do it, and the patient will pay whatever the cash fee might be (as long as we inform the patient about the cost ahead of time). Am I wrong?
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There are a lot of nuances about why a procedure isn't covered. There are also a lot of nuances in your insurance contract about when you cannot bill a patient, and the specific requirements when you do bill a patient.
Something that is not covered because insurance includes it in the work of the other paid procedure may not be billed to the patient. Something that is not covered because it's completely excluded from patient's benefit coverage is likely able to be billed to the patient. Something not covered because the patient maxed their benefits is likely able to be billed to the patient, but you probably should have told the patient prior. There are also federal and state "No surprise bill" laws that may require you to inform the patient prior, along with an estimate of what the patient will owe.
If the EOB bundles one procedure into another, the EOB will indicate the patient is not responsible. If the EOB indicates the patient is responsible, then you may absolutely bill the patient. The exact reason for non-covered is key to whether or not the patient could potentially be responsible, as well as your contract with the payor.
 
csperoni said:
There are a lot of nuances about why a procedure isn't covered. There are also a lot of nuances in your insurance contract about when you cannot bill a patient, and the specific requirements when you do bill a patient.
Something that is not covered because insurance includes it in the work of the other paid procedure may not be billed to the patient. Something that is not covered because it's completely excluded from patient's benefit coverage is likely able to be billed to the patient. Something not covered because the patient maxed their benefits is likely able to be billed to the patient, but you probably should have told the patient prior. There are also federal and state "No surprise bill" laws that may require you to inform the patient prior, along with an estimate of what the patient will owe.
If the EOB bundles one procedure into another, the EOB will indicate the patient is not responsible. If the EOB indicates the patient is responsible, then you may absolutely bill the patient. The exact reason for non-covered is key to whether or not the patient could potentially be responsible, as well as your contract with the payor.
Click to expand...
Ok, that makes sense. So, if the procedure (occipital nerve block or any other) is not covered due to "being experimental" or "non-medically necessary," then I should be able to bill the patient, assuming I informed the patient of the potential non-coverage and the estimated cost to the patient. Am I correct? Is there a template or a form for such a letter (similar to ABN for Medicare)?
 
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