Why Are You Losing Money with ‘Insurance Only’ Billing?

What is ‘Insurance Only’ Billing?

As the name suggests, in ‘Insurance Only’ billing, healthcare practices accept the amount the insurance company will pay and waive patient responsibility portions like co-pay, coinsurance, and deductible amounts. In most circumstances, this puts the physicians and the practices in jeopardy, especially when your client base is Medicare patients. Medicare pays providers the lesser of the reasonable costs or the customary charges for services furnished to Medicare beneficiaries. Practices that routinely waive co-payments and deductibles have been charged with violating Anti-kickback Statute (AKS).

The AKS is a criminal statute that prohibits actions intended to induce or reward referrals for items or services reimbursed by federal healthcare programs. Consequently, discounts or write-offs should never be given to encourage patients to come to a practice. Commercial payers may prohibit waiving or discounting cost-sharing amounts such as co-pays, coinsurance, or deductibles. In certain states, routine waivers of co-pays and deductibles may be considered insurance fraud and may subject practice to criminal liability.

In some states, routine waivers of co-pays and deductibles as a professional courtesy are considered insurance fraud. Routine waivers of co-pays and deductibles and professional courtesy discounts for commercial insurance beneficiaries also can be considered a violation of the AKS if the recipient or a family member is in a position to refer federal health program beneficiaries to the physician or practice. Practices that wish to continue offering professional courtesy discounts should consult a billing expert to evaluate applicable state laws and review practice-specific insurance contracts.

Why Practices Relies on ‘Insurance Only’ Billing?

There are various reasons why any practice would rely on ‘Insurance Only’ billing as a sole source of practice collections, some of them are listed below:

Absence of billing team:

Practices find it difficult to hire experienced billers and coders for their medical billing specialists. Medical billing and coding is a specialized task that requires a specific set of skill set. Practices struggle to form and retain an expert billing team as payroll and overhead costs could be really high. Due to the absence of a billing team, providers are stuck only with the claim submission process and can’t take follow up on every submitted claim. This could lead to accepting reimbursement paid by insurance carriers without appealing their decision.

The provider manages all:

Generally, small practice owners or solo providers try to manage everything on their own. This includes doing medical billing for their practice. As healthcare providers are not trained medical billers, they tend to make mistakes during the entire billing process. In such scenarios, healthcare providers focus on submitting claims without an understanding of billing guidelines and payer reimbursement policies. They tend to use a specific set of procedure/ diagnosis codes for all submitted claims. As the provider is busy with patient care, they won’t be able to review explanations of benefits and has to accept the amount paid by insurance carriers.

Fear of payer audit:

Providers always have a fear of external payer audits and due to this fear, providers tend to accept insurance payments made by payers without any question. As providers are not sure about billing guidelines, even appealing a denied claim is avoided due to fear of such payer audits. In reality, often communications with payers help your practice to understand billing guidelines and avoid common billing pitfalls.

Absence of insurance coverage reports:

Due to a lack of skilled manpower, practices often don’t have insurance coverage reports for patient visits. Insurance coverage or benefits report will help practices to understand if the patient’s insurance is covering the planned treatment and what is co-payment or unpaid deductible amount. Without an insurance coverage report, it’s really difficult to collect a co-pay at the time of a patient visit.

Medical Billers and Coders (MBC) is a leading medical billing company providing complete revenue cycle services. We can assist you in receiving a complete reimbursement amount for delivered services. Our expert billers and coders are well-versed in specialty-wise billing guidelines and payer-specific reimbursement policies. Our benefits report will help you to collect accurate co-pays and unpaid deductibles at the time of service.

With our assistance, you can bring financial sustainability to your practice through timely and accurate reimbursements. To know more about our medical billing and coding services, email us at: info@medicalbillersandcoders.com or call us at: 888-357-3226.