This article is republished by the express written permission of ChiroCode Institute
Presenting Problem

There is confusion on when to bill group health plans as the secondary payer, with discounts, when the auto Med-Pay is used up.

History

Most networks have contractual discounts and might expect providers to apply those contractual discounts.

Findings

Supplemental insurance plans with contractual discounts in the patients’ group health plan are typically not affected by the type of primary carrier. The fact that it is an auto claim is irrelevant. Insurance contracts usually have “coordination of benefits” clauses to address such secondary matters.

Assessment

Without a lien or letter of protection, doctors could be subject to the network discount. It’s all centered on contract law. Here are comments from three subject matter experts:

Kathy Mills: “I agree that contract rules apply. Interestingly, I’ve seen excellent and friendly attorneys assure that their doctors are paid-in-full from settlements. Additionally, they have them bill the carrier, if there is not a subrogation agreement. Then the patient can be reimbursed any amount over the 100% paid to the doctor. I’m always a fan of the attorney who helps make this decision based upon the contract. From a patient perspective, they have paid their premiums and deserve their benefits.”

Dar Crawford: “I totally agree. Our state of Michigan is a no-fault state. If the health insurance is involved and the patient has coordination of benefits or full medical benefits, contract rules always apply.”

Dr. Jeff States says: “A lien or letter of protection should be signed by the patient before billing anyone. Our ‘Health Agreement Letter’ is routinely signed by the patient before billing any health insurance. This letter indicates that the patient agrees that the lien supersedes any and all other contracts, and that any amounts paid by the health carrier will be deducted from their obligation (bill). Consequently, any payer policies regarding fee reductions is irrelevant. For example: If the bill is $100 and the carrier pays $50, the balance of $50 is protected by the lien or letter of protection.”

“There are no guarantees, but hundreds of offices have successfully used this protocol. If the patient is unwilling to sign the letter, or the letter does not work within a particular community, I would NOT bill anybody else. I’d then have the patient pay the balance and/or protect the balance by the lien.”

Plan
  1. Use a letter of protection.
  2. Avoid risks by not billing the secondary directly whenever possible.

Encourage the patient to use their legal counsel for any billing to secondary payers.