Q/A: How Do I Respond to a Patient's Request to Not Submit the Claim to Their Insurance?

by  Wyn Staheli, Director of Content - innoviHealth
May 7th, 2018 - Reviewed/Updated Jan 30th

Question

A number of patients now have high deductible plans. Sometimes, deductibles can be $5000 or $10,000. My payer contract states that I must submit all claims to insurance for covered services. However, sometimes patients with these high deductibles come to my office and state that they would prefer to receive a modest discount for paying cash and in turn, not have their services submitted to insurance. As a doctor, this places me in a tough situation. Do I follow the patient's wishes or the payer contract?

Answer

HIPAA's "Out of Pocket” provision allows a way for you to honor your patient's wishes. However, ALL of the following criteria must be met:

1. The patient completes a "Request to Restrict" disclosure form
2. The disclosure is to a health plan for payment or health care operations
3. The disclosure is not required by law (e.g., court ordered)
4. The protected health information pertains solely to healthcare for which the patient (or someone on behalf of the patient) has paid for in full out of pocket (partial payments do NOT count)

As a provider, you must ensure that you have that patient encounter information flagged or tagged differently than other patient encounters to avoid an inadvertent disclosure to their insurance which would be a HIPAA violation.

Be sure that the patient understands that they CANNOT come back and ask you to submit the claim to the insurance AFTER the fact.

Note: Be sure your HIPAA Notice of Privacy Practices specifies that they have this option.

The appropriate disclosure form (Patient Request(s) Regarding Healthcare Records) is part of the HIPAA Compliance product and can be downloaded after purchase.

ALERT: For more information about high deductibles, cash plans, fee schedules and more, there's a webinar tomorrow. CLICK HERE to register.