It's not as simple as that. You see, if your provider was not contracted with the patient's HMO and agreed to treat the patient without talking to the patient and without contacting the HMO to see if authorization was required, then the doctor has to accept responsibility for his actions.

Actually, you may not be able to bill the Medicare HMO patient unless the HMO denies the claim for no coverage or for non-par reasons. Unless you have seen the patient's benefit manual, you don't know if the patient is responsible for charges when they go out of network. Not all Medicare HMOs have the same policies.

If you haven't submitted the claim, then you need to do so. If they denied the claim, then look at the reason for the denial. If the denial is because the services were rendered by a non-par provider, then you could bill the member. If the HMO pays, all they have to pay is the Medicare fee, including copays and dedictibles.

United and Aetna have sent letters to all non-par providers stating that they will no longer send payment to the non-par provider. How I handle these is I have informed Aetna and United that I will no longer send claims as a courtesy to their member. Their members must pay my provider 100% of billed charges and the member can send their own claims.

Be careful on these "contracts" you are signing. The insurance company could take this to mean you have now contracted to be paid at the agreed upon rate for all products and all affiliates. I only give a discount when I receive payment within 5 calendar days of the signing of the agreement, and even then, if the agreed payment is not received within 5 days, the agreement is terminated and 100% of charges is to be paid. I also state that the agreement is for this claim and this date of service only.