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  1. #1
    Join Date
    Apr 2009
    Posts
    2

    Default Billing for Services (Part Covered by Insurance and Part Uncovered )

    My question involves insurance law for the state of: Massachusetts

    I am a developmental pediatrician in MA. I conduct evaluations of children with suspected developmental delays. I initially planned to simply be fee for service and not take any insurance. Now, I am considering contracting with one insurance carrier that is popular in my area. The insurance company offered me a reasonable reimbursement for my services but I work with a team of individuals (speech pathologist and occupational therapist) whose services would not be adequately reimbursed.

    So, my question is this. Is it legal for me to accept insurance for my portion of the evaluation and charge the patient for the speech and OT portions. I would be upfront with the patient about the out of pocket expense and they would only book an appointment if they were comfortable with those fees. If they were not comfortable they would not be offered an appointment because I only see children as part of the team evaluation (ie. they can't just see me if they want to at this office).

    The speech pathologist and OT are employees so I question if they are allowed to not accept insurance if I do (even though they do not have an individual contract with the insurer).

    I also wonder if this would be seen by the insurance company as balance billing because there would be some out of pocket expense to be seen at this site. I didn't think so because it is NOT my balance they are being charged but to be honest I am not sure how this could be viewed.

    thank you for any help you can provide and I am happy to provide more information if needed to clarify any ambiguous points.

  2. #2
    Join Date
    Mar 2008
    Posts
    176

    Default Re: Billing for Services (Part Covered by Insurance and Part Uncovered )

    are each of you billing separately for your services? are you billing all under the same tax id number or separately? normally if you contract with the insurance company, it is per individual provider. if you all bill under a corporation name, i would assume the head of the corporation is the one who would have to negotiate with the insurance company. it also depends on the way the contract is written between the insurance company or the PPO and you or the other individuals in the practice.

  3. #3
    Join Date
    Apr 2009
    Posts
    2

    Default Re: Billing for Services (Part Covered by Insurance and Part Uncovered )

    Right now the business is set up totally fee for service and we provide each patient with an itemized list of cpt codes and detail what we have done along with the printed report that families can use to get reimbursed for services if they can go out of network.

    I am set up as an LLC and am the single owner while my OT and SLP are employees. I guess I don't know if different people can be set up differently as part of the same business.

    I know that if I want my slp and OT be able to accept the insurance plan they need to be individually credentialled which they are currently not. does that help?

  4. #4
    Join Date
    Jan 2006
    Posts
    38,728

    Default Re: Billing for Services (Part Covered by Insurance and Part Uncovered )

    Quote Quoting addison315
    View Post
    I know that if I want my slp and OT be able to accept the insurance plan they need to be individually credentialled which they are currently not. does that help?
    are you saying these people are not licensed for the services they provide?

    I hope not. Billing for services that require a licensed practitioner where the provider is not such would be insurance fraud regardless who employs them as well the action would also be in contrast to the Massachusetts state laws.

    if you mean that simply they are employees, then their employer is the entity that determines not only their pay but contracts with any given insurance company.

    Do you (your LLC) employ these people or are they employed by some other entity. You (your LLC) can contract independently of another company but if the therapists are employees of your LLC, you are in an all or nothing situation with the insurance company. You (your LLC) is bound by whatever the contract with the insurance company allows. If they are employed by another company, they are bound by their employers actions and cannot bill indepedently of their employer.

    If they are employed by another company, that company can contract with an insurance company and subsequently be bound by that contract or they could refrain from such contracts and bill as they desire.

    In most situations, it is the patients responsibility to determine if a provider is within their PPO or HMO and subject to the discounts demanded by the insurance company. It is alway wise to disclose to a patient that the services are provided by more than one company and they should consult their insurance as to PPO or HMO provider status.

    Oh, and be forewarned; For these therapists to become independent contractors as opposed to employees; there are rules as to who can be an IC and who must be considered an employee. Contracting with them as an IC will alter your business relationship with them. You will lose much of the control you currently are afforded in regards to how they run their business as well as your and their tax situations.

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