tci Medicare Compliance & Reimbursement - 2013 Issue 14
Reader Question: Avoid Skirting the System to Save Patients Money
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Article Overview
This article addresses a billing and compliance question raised by a practice seeking to charge a patient directly instead of submitting the claim through insurance. It focuses on the general relationship between payer contracts, patient cost-sharing, explanation of benefits processing, and the difference between participating and non-participating arrangements. The discussion is relevant to medical office billing staff, practice administrators, and compliance-focused revenue cycle personnel who need a high-level understanding of the issue before reviewing the full guidance.
Why This Topic Matters
The topic matters because billing a patient outside the normal claim-and-EOB process can create compliance risk and uncertainty about patient responsibility. Practices need to understand the general framework for handling deductible-driven patient requests without violating payer agreements.
What You Will Learn
- How payer contracts affect whether a claim should be submitted
- Why explanation of benefits information matters in determining patient responsibility
- Why different health plans may result in different patient payment amounts
- How participating and non-participating practice arrangements differ at a high level
Who Should Read This
- Medical practice billing staff
- Revenue cycle professionals
- Practice administrators
- Compliance personnel
- Physician office managers
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