Legally, you are not required to bill a patient’s secondary insurance plan if you are out of network. Instead, you can choose to bill the patient directly, but doing so can put you at odds with the No Surprises Act implemented Jan. 1st of this year.
This new regulation requires that you follow very clear steps when billing patients for out-of-network services. Failing to comply with this new rule can get you audited and leave you paying hefty fines (not to mention a loss of the reimbursement you are due).
So, why bother to bill the patient directly if it opens you up to additional compliance scrutiny? The main reason is an increase in your reimbursement. As an out-of-network provider you are most likely paid less than in-network providers for the same services. However, if you bill your patient directly, you are allowed to do so at the higher in-network rate.
Get paid at in-network rates and improve your No Surprises Act compliance with the steps below before billing for out-of-network services.
Prepare Your Staff
Remember that the goal is for your patients to have no surprises regarding what they will be required to pay for out-of-network services. To facilitate this goal, it is imperative that your staff is fully trained and able to answer your patients’ questions quickly and efficiently.
Your front office staff will most likely be on the firing line when it comes to answering patient billing questions – typically during the check-in and check-out processes. Accordingly, take the time to walk your front office staff through your billing policies, in detail.
To help your front office staff better answer patient questions, consider providing them with a cheat sheet they can keep at their desk with common questions that patients might ask. You should also make sure your team has extra copies of your out-of-network billing policy to provide to your patients should it be requested.
Patient Notifications
Before you bill your patients for out-of-network services, they must be clearly notified – so that there are no surprises.
You are required to notify your patients at least 72 hours before they receive out-of-network services. This provides them with ample time to receive the notification, ask any questions, and decide if they want to receive their care from your practice or one that is in-network with their secondary plan.
In addition to this initial notification, consider reminding your patients each time they check-in that your practice is out-of-network with their secondary insurance. It is also a good idea to reiterate that they will be responsible for this portion of the amount due. Sometimes people need to hear the same thing multiple times before it really sinks in.
Modify Your Financial Policy
It is important that your practice’s financial policy be clear regarding how you will bill for out-of-network services (as well as any other financial policies your practice has in place). Some items to add to your financial policy to ensure patients are completely informed of your out-of-network billing policies include:
- That your practice will no longer bill non-contracted secondary insurance companies
- Patients will be responsible for any charges not covered by their primary policies
- Patients may receive estimates for non-covered charges by request
- Payment for out-of-network services will be collected prior to service based on the estimate you received.
Setting up the expectation from the beginning that payment is required prior to service helps your patients come prepared to pay, making it easier on your front desk to collect. To help remind your patients of this expectation, consider posting your new financial policy in your waiting areas, in patient rooms, and on your website. It may even be a good idea to include notification of your policy change in any other patient communications you send (i.e., invoices, etc.).
The more times you repeat that you are not going to bill non-contracted secondary insurance to your patients, the easier it will be for them to remember when you ask them to pay. Over-communicating is always better.
Note: Should you ever get audited for No Surprises Act compliance, it will be important that you’ve documented all these patient notifications. You should also include, in your practice’s compliance documents, that you posted your revised financial policy at your front desk and made additional copies available upon request.
Good Faith Estimates
The No Surprises Act requires you to provide good faith estimates to self-pay patients and when they are requested by patients with insurance. However, you are not required to provide Good Faith Estimates to patients who have insurance, regardless of your network status.
Patients who have secondary insurance policies that aren’t in network with your practice may request that you provide an estimate for the charges they can expect to pay, and you should be prepared to promptly make these available.
Patient Collections
After your patients have been adequately notified of your out-of-network billing policy, signed your financial document, and been provided a good faith estimate of the cost (if they required one), now it is time for your practice to be paid.
Your staff will have a higher collection rate if they ask for the money up front before the out-of-network service is provided. However, there will always be those patients who have an excuse not to pay.
To help combat these excuses, consider doing a training with your team that provides them with answers to the most common payment excuses. When preparing for the training, ask your front desk team to submit their craziest excuses to include. This will help your staff be more vested in the training, and it will be more fun.
But what if your patient simply refuses to pay? Should they still be allowed to receive their treatment that they’ve arrived for?
In these sensitive situations, it is never a good idea to let someone at your front desk make the call on a patient treatment. This can come back to bite you if the services being provided are necessary for the patient’s well-being. Instead, consider setting clear guidelines for your staff to hand off the situation to the practice manager or even the provider involved.
Same Rules for All
Finally, be sure you have one policy for everyone. Muddying the waters by billing some non-contracted secondary insurance companies but not billing others will cause confusion for your staff and patients and could lead to mistakes.
Choosing to bill patients directly instead of their secondary plan for out-of-network services can increase the amount of reimbursement you receive. However, the increase in revenue could be short lived if you fail to comply with all aspects of the No Surprises Act.
Billing insurance can get tricky, and the legal changes brought about by the No Surprises Act made it even more challenging. Get step-by-step, expert advice in Healthcare Training Leader’s 3-part online training series, Cut Confusion, Master No Surprises Act Changes. Billing and legal experts walk you through the changes to the No Surprises Act and what you need to do to stay compliant. Access this training series on your schedule.