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Hi All. I was wondering if anyone can point me to documentation that says it is either legal or not to collect a credit card from a patient with insurance or medicaid for a deductible at the time of “purchase” with insurance to cover a remaining balance (difference between a product’s retail price – what insurance pays), if any. For example, a DME supply is $100 and a patient’s insurance indicates it will only pay $80 for that code, then can we charge them the $20 upfront? Can you also make an agreement with the patient that if there insurance does not eventually pay then we can charge the other $80 to that patient’s credit card on file? Would it matter if we, the DME are in or out-of network with that insurance company? Appreciate the help on this complex issue! #insurance #DME #durablemedicalequipment #medicaldevice #start-up Marked as spam
 Posted by Asked on October 20, 2016 12:00 am
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Private answer
Greg Switzer
Obviously, an actual legal opinion from qualified and compensated counsel is in your best interest. However, if you are 'in the network' of the payer, than you have already agreed to terms (whether you know it or not) regarding how and what you can collect and when. If you are not, the decision for you is to determine the value of your product, the patient accepts it or not, then pays for it or not, and if they do it is their responsibility to get reimbursed, not yours to figure out how to collect. This is our new world, although patients are having a tough time realizing it. Hope things are going well for your company.
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Private answer
Assuming you are in network, most insurance companies will have an allowable/contractual amount in which they reimburse on a HCPC code. This seems to come into play once the patient's deductible has been met. In the instance it has not, some insurances will apply the full bill charge to their deductible, in which case collecting at time of service would be in your best interest. Greg makes a great point if you are out of network in determining value of your product, however, there may also be out of network benefits for that code (i.e. 50% coins for OON vs 20% for in network). Of course, the patient can be held responsible for having their out of pocket cost reimbursed by their insurance company. I hope this helps.
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Private answer
Caitlin Morse, PMP
I don't have a document to point you to, but I have researched this as a patient and received the same answer from multiple sources (insurance companies and medical providers)
"Allowable Amount" - the maximum that an insurance company will recognize as due. This is separate from deductibles, % of coinsurance, etc. If the provider is in-network, they have agreed that this is the most they can charge the patient/insurer and cannot require the patient to pay the difference. If a provider is out-of-network, they have not made any agreements and can require the patient to pay the difference (the $20 in your case), an informed patient may choose a different provider rather than pay more. If the deductible has not been met and the provider is in-network, the patient is responsible to pay the total "allowable amount" only. If deductible has been met, then co-insurance %. Yes, most clinics and hospitals have a statement that patient is responsible if insurance doesn't pay. Marked as spam
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