Out of Network Billing

[Guest guest]

I have just started insurance billing in my practice but am only out of network.

I have one patient with Medicare as primary and a full Federal BCBS plan as

secondary. Medicare will not process my claims enough to give me a denial so I

can pursue filing with BCBS, and BCBS will not process the claim without an EOB

or denial from Medicare.

Has anyone dealt with this? I think the patient would be happy to submit the

paperwork themselves, and that may be the best way to go, but need to develop a

system for this issue in the future as well.

Thanks.

Weller PT, MPT, ATC

Integrative Biomechanics

New Orleans, LA

[Guest guest]

I have encountered this situation as well. In some cases, a commercial carrier

will accept the letter Medicare sends you stating they cannot process your claim

along with an affadavit from the provider testifying to the fact that she is not

a Medicare provider and is therefore unable to provide a Medicare eob with the

claim.

However, I was not successful using this method when BCBS was the secondary.

Since you are out of net with BCBS, I believe having the patient file the claim

herself would be the best route to take. Patients can usually find claim forms

on the carrier's website.

In the future, you may wish to have a policy in place stating that in these

scenarios the patients are told in writing ahead of time that they will need to

file the claim to their secondary carrier directly. Collect payment up front and

when the patient files her own claim, the carrier will reimburse her directly.

If you applying to be in-network with some carriers, I would recommend asking

for their policy on handling this scenario when you are in-network with the

commercial carrier and it is secondary to Medicare. Then you will know how to

proceed on these types of cases before they arise.

Cheri Freeman, CMRS

Manager of Account Services

Healthcare Reimbursement Services, LLC

Austin, TX

>

> I have just started insurance billing in my practice but am only out of

network. I have one patient with Medicare as primary and a full Federal BCBS

plan as secondary. Medicare will not process my claims enough to give me a

denial so I can pursue filing with BCBS, and BCBS will not process the claim

without an EOB or denial from Medicare.

>

> Has anyone dealt with this? I think the patient would be happy to submit the

paperwork themselves, and that may be the best way to go, but need to develop a

system for this issue in the future as well.

>

> Thanks.

>

> Weller PT, MPT, ATC

> Integrative Biomechanics

> New Orleans, LA

>