Q regarding doctor's billing requirements

Factual Questions
1

There are actually two things on this doctor’s paperwork that I have not encountered before. This is in Illinois.

One requires me to agree that, if I self-pay for some procedure or office visit, I promise not to bill my insurance company for doctor X’s provider fees. (I am not sure what significance the phrase “provider fees” has, as opposed to just the doctor’s fees. I assume it is just verbosity for the sake of sounding more legalistic.)

In other words, if I pay the practice when the service is rendered, I am not allowed to later file an insurance claim with my health insurance to get re-imbursed?

The other “new to me” item is a Direct Assignment of Benefits form, that allows the practice to deposit checks received on a patient’s account when made out to the patient.

These both give me kind of a WTF? response… but the doctor was recommended by my doctor and he seems to have a solid and highly respectable resume.

Now, it is my previous experience that if a doctor’s office files an insurance claim with my insurer on my behalf without requiring payment at the time of service, the bill gets reduced according to the insurer’s agreement with the practice, the insurance then pays whatever they are obiligated to pay, and then I am billed by the practice for whatever amount is left over. When the insurance pays something to the doctor, they pay the doctor’s practice directly, in the practice’s name. (at least, this is what I’ve always assumed…)

If I have to pay at the time of the service (at those practices that require that), I pay 100% and then either the practice or I file the claim and the insurance company re-imburses me by check mailed directly to me in my name, for the amount that they would normally have been obligated to pay.

Nowhere have I encountered a situation where the insurance company would mail the practice a check in my name. Does that ever happen?

I have not actually seen the doctor yet, and a call to the office about these questions was met with a “bring the paperwork in and we’ll discuss it on the day of the appointment” so I thought I would ask here to see if this is common.

I do not know if this practice requires payment at the time services are rendered or not. If it does, with the requirements above, I think it smells awfully fishy.

If it makes a difference, this is a plastic surgeon’s office.

2

I don’t have too much to do with our billing side but I do know that many places have separate “self-pay” fees. It comes out of the realization that full retail is a fiction that no insurance company pays and that only those who are uninsured are sometimes asked to pay. The concept is to offer the self-paying (usually meaning uninsured) patient a similar discount schedule as being given to the insurers intead of that fictive full retail. That would not work if the “self-pay” then is actually then submitting the bill to the insurer.

And insurers are supposed to send the check in the practice’s name but screw it up more often than you’d think. The direct assignment is simpler than trying to get the insurer to take back the check and resend it in the practice name.

In truth I do not know how our billing does it.

Plastic surgery is often functionally considered “retail medicine” … much more is done that insurance does not cover, that does not “need” to be done, but that people are willing to pay for out of pocket … that may impact billing policies as well.

3

Thanks, DSeid.

I suspected the “plastic surgery” detail might have some relevance. I googled the exact wording on the authorization that I was concerned about, and the only hits were two other unrelated plastic surgery practices.

Well, guess I’l ljust have to wait until I can talk to someone at the practice.

4

For the insurance companies I’ve worked for it depends on if the provider is in-network or not. If it’s an in-network provider they file the claim, and payment is made directly to them. For out-of-network providers either the provider or the member can submit the claim, but the payment will always sent to the member and it’s on them pay the provider.

5

I actually found a couple of Direct Assignment of Benefits forms online and there are two things they have in common

  1. They both direct the insurance company to pay the provider directly and only if the insurance policy prohibits that , it then instructs that the check be made out to the patient and sent to the temporary address at the provider’s office.

  2. They both say that the payment will not exceed the total indebtedness to the provider.

    It sounds like the arrangements some dentists have - I’ve never found a dentist who was a participating provider with any of the dental policies I’ve had. Often, what happens is that enough work is needed to require pre-authorization. Along with the authorization comes an explanation of how much the insurance will pay- which is always much less than the fee. Some dentists take that into account when collecting payment from me- Fee $1500, insurance pays $500, collect the other $1000 from me. In those cases, the dentist has me sign the “assignment of benefits” section of the claim form, and the insurance company sends the $500 directly to the dentist. In other cases, the dentist collects the whole $1500 from me, and I keep the $500 check from the insurance company. Either way, I end up paying $1000 the insurance pays $500 and the dentist gets $1500. But without the assignment of benefits, I have to lay out the whole fee and await reimbursement for part of it.