The issue of whether a payer will receive and/or accept electronic claims from the above has been a long-standing topic on this list and specifically, the identification of such a non-par/out-of-network provider.
On the HIPAAlive list earlier this week a provider attached its proposed policy that I believe touches on this issue. I've extracted the text of that policy here: Policy 6500: Payment The Practice requires payment from each patient at the time of service, unless the patient has health insurance coverage in place, provided by an insurance plan that the practice participates with. A patient covered by an insurance plan that the practice participates with will be required to pay the plan co-payment at the time of service. In the event that a properly completed claim submitted by the Practice for care provided to a patient is denied by the applicable insurance plan, for whatever reason, the patient shall be billed for the service. HIPAA: The Practice shall not agree to restrictions requested by a patient in the disclosures of PHI for PTO purposes which might interfere with the Practice’ s ability to receive payment for services rendered to the patient. Under no circumstances will the Practice knowingly file a false or incomplete claim with an insurance company, nor will it knowingly provide the patient with a false or incomplete encounter form which the patient might file with an insurance company. Procedures: 1. For Practice patients: a. If the patient is covered by an insurance plan that the Practice participates with, the plan co-pay is to be collected. b. If the patient is a self-pay, 100 percent of that day's services is due at the time of service. c. If the patient is covered by a plan the Practice does not participate with, 100 percent of that day's services is due at the time of service, and the encounter form will be provided to the patient so the patient may bill his/her insurance carrier. The Central Billing Office does not provide courtesy billing of nonparticipating insurance carriers and secondary insurance. 2. Requests for restrictions on disclosure of PHI: a. If a patient would like to avoid disclosure of certain PHI related to an episode of care to his or her insurance plan, the patient must pay in full for the services rendered at the time of service. The Practice will not otherwise agree to the requested restriction. b. If the patient requests limits to communications with the Practice to avoid disclosure of PHI to family, employer, coworkers, et al. such that the Practice may not be able to resolve common billing and collection matters in a timely fashion, the Practice shall not agree to such requested restrictions unless the patient agrees to pay in full for services rendered at the time of service. 3. If a patient is being seen for an employer-authorized work-related injury, the Practice will bill workers' compensation directly. If the employer's verification of injury cannot be obtained, patient will be told that he/she may be ultimately responsible for payment and private patient billing information is obtained. 4. If patient is employed by a company that has established an account with the Practice and the employer has authorized the visit, the Practice will follow the billing arrangement established with the employer. Authorization can be written on the standard Practice Authorization form or by phone. Phone authorization must be documented in writing by the Practice staff on the authorization form. The authorization form is placed in the back of the medical chart. 5. Medicare assignment is accepted and the Practice will bill directly for services. In many instances, patients will be required to make a payment of deductible or coinsurance after Medicare has paid for the service. The question that leapt into my mind as I read this Payment Policy is that this provider is clearly stating it will not file claims on behalf of the patient to a health plan with which it does not participate. Is this the common practice today? If yes, will this continue to be the common practice into the future and for how long? If yes, then is the issue of identification/routing of transactions to payers from non-par/out-of-network providers one that should require a lot of analysis/discussion, but rather be put in a "parking lot" for future work effort? Rachel Foerster Principal Rachel Foerster & Associates, Ltd. Professionals in EDI & Electronic Commerce 39432 North Avenue Beach Park, IL 60099 Phone: 847-872-8070 Fax: 847-872-6860 http://www.rfa-edi.com discussions on this listserv therefore represent the views of the individual participants, and do not necessarily represent the views of the WEDI Board of Directors nor WEDI SNIP. If you wish to receive an official opinion, post your question to the WEDI SNIP Issues Database at http://snip.wedi.org/tracking/. Posting of advertisements or other commercial use of this listserv is specifically prohibited.
