THE QUESTION: THE PATIENT HAD TOLD ME THEY’RE OK MOVING FORWARD COSMETIC AND HAVE NOW BILLED THE INSURANCE COMPANY ON THE BACKEND, FORCING US INTO THE BILLING PROCESS. ANY WAY TO AVOID THIS IN FUTURE?
We were asked a really good question about insulating against patients submitting self-pay cases to their insurance after the fact- see below.
Have you seen any waivers/ documentation to protect against this?
How do we insulate against patients submitting self-pay/cash-pay/cosmetic cases to their insurance after the fact? Have you seen any waivers/documentation to protect against this?
We’ve seen language, but we’re not attorneys nor is this little blurb blessed by one…so ask yours for formal language please. That said, we’d put this right there on the Quote you have the patient’s sign for self-pay pricing.
“I understand that my procedure may be considered medically necessary and am voluntarily choosing to move forward with my provider in a cash-pay format. I am electing NOT to utilize my insurance benefits and/or to have my case reviewed for medical necessity prior to surgery. I have agreed to pay a cosmetic fee up front to the provider and do release the provider from assignment of benefits. I understand that the provider will not be able to assist me with any billing and do not intend to submit charges for these services to my insurance carrier retroactively for coverage.” ??
Essentially you want to be able to show the insurance company that the patient chose to enter into a direct contract that supersedes your provider-insurance carrier contract.
Why does this occur?
Often times these procedures are “on the line” of medical coverage, or “grey area,” sometimes they’re clearly cosmetic and other times they may actually be medically necessary…but the patient wants to be on the books tomorrow and you don’t have time for an auth etc.
Basically they pay… usually to get on the schedule faster… and then get “buyers remorse” and think “well why shouldn’t I trrrrrry to get something from insurance?” ??
It’s just how it goes unfortunately.
So you’re saying part of the answer is to say to the insurance company, “back off, your client already ruled you out of the payment process” sorta thing?
Correct – we’re telling the insurance company “forget your contract, this patient chose of their own volition to move forward and has reneged on that decision. We are not obligated to your contractual obligations because the direct vendor to consumer contract supersedes.”
The bottom line is no matter what your paperwork says, the payer is going to tell the patient you HAVE to bill. They don’t encounter aesthetic cases much. They don’t understand insurance contracts. They are there to get the patient off the phone with the answer they want to hear. So, guess who the patient is coming back at to “help” with the process no matter what you discussed or what they signed…you guessed it…you.
There’s no way to really stop this, but by papering the decision-making process, you give yourself some legs to fight it at least. ✅