Legal Question in Health Care Law in California

Healthcare Law

I need clarification on the following issue. As a contracted healthcare provider, I would like to know what my responsibilites are to an insurance carrier. If a patient does not present their insurance info at the time of services being rendered am I still responsible to bill their insuran? They negotiate cash discounts , receive the services then return in a couple of weeks and ask that I bill the insurance carrier. Especially after all their required forms were completed for their office visit which included an immigration exam. When I bill these discounted rates the insurance carrier only reimburses us a percentage based on the pateints policy and coverage. When I addressed this issue with a couple of large carriers, I was given the impression that because I was a network provider I was obligated to the patient to bill their insurance, only to get paid less the contracted rates. Does the patient not have a responsibilty as well? It seems that the insurance carriers are supporting this practice. When a patient requests a discount we offer it to them at a rate assuming they cannot cover their cost, and we consider our profit margin at a much lower rate becuase there would be no labor involved to get the claim submitted and paid.


Asked on 11/12/07, 12:22 am

2 Answers from Attorneys
Armen Tashjian Law Offices of Armen M. Tashjian

Re: Healthcare Law

Your question involves basic contract law, that is, are you obligated to accept patient's insurance only?

The answer is in the agreement between you and the subject carrier (unless we're dealing with governmental entity.)

If there is an agreement between the carrier and you, they you should read that agreement to see if balance billing is allowed. If so, you can charge the balance to the client.

Good luck,

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Answered on 11/12/07, 12:05 pm
Gregg Gittler GITTLER & BRADFORD

Re: Healthcare Law

Generally, if you are a provider under an HMO (or PPO preferred provider) contract with an insurance company or healthplan, you probably agreed with the carrier to accept only a designated co-pay or percentage from the patient, and then only the provider's discounted rates set forth in its contract with you.

It is unclear whether you receive payment from the patients at the time of service (or before) or whether you negotiate a cash discount, perform the services, and still do not get paid. If it is the former, you received an acceptable fee from the patient at the time of service because you were not advised of the insurance coverage. If the latter, you need to change your business practice.

In either event, you should have an attorney review your network contracts and advise you of your rights and obligations under those contracts, and to help you develop a business plan for billing and collecting from patients accordingly.

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Answered on 11/12/07, 1:32 pm


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