How do you collect payment for services the insurance company won't pay for?
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What do you do when y'all are presented with a patient who needs treatment but the patient's insurance company volition not pay for the services? Can you provide the services anyway? Who volition pay for them? How practice y'all collect payment for such services?
If the patient consents to receive the services in spite of the insurance company'due south refusal to pay for such services, you will probable exist able to bill the patient direct. Yet, in order to exercise so, at that place are certain requirements that you must satisfy.
Reason for Non-Coverage
Several reasons exist for why a particular service may not be covered by Medicare, Medicaid or a commercial insurance provider. Medicare specifically identifies four categories of items and services that are not covered, which are by and large applicable to commercial payers every bit well. The four categories are:
- Services that are not medically reasonable and necessary;
- Non-covered services;
- Services denied as bundled or included in the basic assart of some other service; and
- Services reimbursable by other organizations or furnished without charge.
With respect to the first category, services that are not medically reasonable and necessary to the patient's overall diagnosis and treatment are not covered. To exist considered medically necessary, the services must meet specific criteria defined by national coverage determinations and local coverage determinations. For each service billed, yous must identify the specific patient symptom or complaint that necessitates the service.
Concerning the second category, some services are simply non covered by certain payers. These include, but are non limited to, services furnished outside the U.South., sure routine physical checkups, eye examinations, eyeglasses and lenses, hearing aids and examinations, certain immunizations, personal condolement items and services, custodial intendance, and cosmetic surgery.
Regarding the third category, services that are denied as bundled or included in the basic assart of some other service include fragmented services that are part of the basic allowance of the initial service, in addition to prolonged care, medico standby services, sure case management services and supplies included in the basic allowance of a procedure.
In relation to category four, some services are reimbursable under auto, no-mistake or liability insurance, or workers' compensation programs and, therefore, are not covered by Medicare. As well, payment will not be made for the following: certain services authorized or paid past a government entity; services for which the patient, another individual or an arrangement has no legal obligation to pay for or replenish (e.one thousand., X-rays or immunizations gratuitously furnished to patient without regard to patient's ability to pay and without expectation of payment from any source); defective medical equipment; medical devices under warranty if they are replaced free of charge past the warrantor; or if an adequate replacement could have been obtained gratuitous of charge under the warranty just was purchased instead.
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