There is a coding and billing trilogy. The trilogy consists of (1) The provider, (2) The insurance company and (3) The patient.
With patients, you have two types. One I call self pay and the other I call uninsured. The self pay patient is someone who has insurance benefits. A claim for benefit payment is sent to the insurance company. After the claim is processed, the provider converts the account from insurance responsibility to patient responsibility. After claims processing, the patient may be responsible for payment of account balances due to (1) the difference between the insurance company payment and the provider's usual and customary charges, (2) unpaid copays, (3) deductibles or (4) coinsurance. This type of patient is what I call self pay. The other type of patient is what I call uninsured. These people have NO health insurance benefits. The uninsured patient is usually responsible for full payment of the provider's usual and customary charges.
I separate insured and uninsured patients. By doing this, I am able to know whether I can provide discounts that are requested from the uninsured patient. I can also run requested reports from my provider. He may want to know how many insured patients never paid their contracted coinsurances and deductibles. He may use this information in contract negotiations. He can also know how many uninsured patients he is treating. It is permissable to provide a discount to an uninsured patient. The OIG published this several years ago. The OIG didnt say it was permissable to provide a discount to an insured patient with a contracted out of pocket payment. The insured patient may be a Medicare, Medicare HMO patient or know a fellow Medicare/Medicare HMO patient. Giving a discount could be seen as an incentive to self-refer or refer other Medicare/Medicare HMO patients which might be a violation of the Stark Act. It could also be viewed as a possible violation of the False Claims Act. The insurance company could view a discount as a possible contract violation as well as a loss of revenue.
The insurance company could also take the position that if the provider routinely provides payment discounts, they can apply a discount to the claims payment as well as establish a discounted payment through contract negotiations. Their response might be, this is all we pay providers for this service.
The uninsured patient may consider allowing discounts, whether the discount is provided through accepting a discounted payment from the insurance company or via a patient, discriminatory because they are treated differenly than an insured patient. Fairy Tale Time: Lets say Red Riding Hood is an uninsured patient. The Big bad wolf is insured through ABC Insurance. Dr Beeker provides chiropractic services. His fee for the service is $250 per visit. ABC Insurance pays 65% of the Medicare allowable which is 15% of Dr Beekers charges. Red Riding Hood is required to pay $250 for the visit. Dr Beeker is paid $37.50. Red Riding Hood feels she shouldnt have had to pay $212 more than her friend Big Bad Wolf, so she files a class action lawsuit on behalf of all of Dr Beekers uninsured patients.
Again, I categorize self pay as someone who has insurance but is now responsible for payment. Uninsured are not categoized as self pay. They are simply uninsured in my system. Both are treated the same except for discounts. I follow my provider's discount policy which, per the OIG, does allow a discount for uninsured patients.
