21 High Street, P.O. Box 219
North Andover, MA 01845
Tel.: (800) 490-0098
Fax: (978) 651-2156

Navigating Successful Practice Management



Medical Billing Practice Answers Common Questions

After 25 years in the medical billing service business, at Bradford Medical Associates we have heard all the questions. The complexity of medical billing has increased dramatically and continues to do so. Two questions we hear from our doctors, regularly are:

1) Is it legal to …..?

2) Will the insurance company pay for it?

While both are excellent questions, there really is no easy answer.

Is it legal to …..?

It depends on whether there is a State or Federal Law regulating what is being asked. For example, “is it legal to balance bill a patient?” The answer can be yes… and it can also be no. Massachusetts laws prohibit balance billing of the patient. Many state laws, including Massachusetts, prohibit billing the patient if the patient has a valid work related injury. But, if the employer or insurance company says the injury was not work related, then the patient can be billed directly.

Also, if a patient is covered by an HMO insurance plan, there are restrictions as to which primary doctor or even which hospital facility is required to pay. If a patient knowingly “goes outside the network” to receive care, he may be billed for additional costs over and above the visit co-pay amount, i.e. deductibles, co-insurances or denials. It should be standard operating procedure for the doctor/practice to have the patient sign a waiver upfront in order to insure that everyone is “on the same page” and that additional charges from the doctor will not come as an unexpected surprise.

As you can see, whether something is legal or not has many different variables. You need to look at the law, not only to see what it does say, but also what all the different possibilities may be.

Will the insurance company pay for this procedure?

No one always knows the answer to this, not even the insurance company! As we all know just because someone has insurance, doesn’t mean that the care being provided is a benefit that the patient is entitled to receive. Many patients and doctors assume that because health insurance is in place, everything is covered. Well, it isn’t. For example, let’s say you have a patient who has had Medicare for 5 years. The patient wants a yearly routine physical. But, Medicare doesn’t pay for routine physicals. Why? It is just not a benefit that Medicare offers to its patients.

Even if the treatment is a covered benefit, there are several other variables to be considered. The doctor may have performed multiple treatments that are designated as bundled by CCI (Correct Coding Initiative) edits, or an insurance company’s coding and billing policies, which can vary from insurance to insurance. The patient may have to have authorization or pre-certification to have the procedure performed. There may be timely filing limit requirements in the doctor’s contract to have the claim received by the insurance company. The patient may have a clause in their contract that if they seek care from an out of network provider, then the care will not be paid for by the insurance company. Even if you think that you did everything right, there is no guarantee that the claim will be paid.

If you have a question as to whether something is legal or whether an insurance company will pay, please know that the answer requires research. Laws must be read, insurance contracts and provider contracts must be thoroughly reviewed, and patient benefit manuals must be looked at carefully to come close to providing an answer. Even after doing all of that, the answer may still not be there. But as you read and research, you will gain a better understanding of what is there and of the different avenues that you can travel to get as close as possible to finding the answer.

At Bradford Medical Associates we handle billing issues and questions like these all the time on behalf of the practices we represent. We have more than 25 years of experience in every aspect of billing and automating medical practices of every specialty, both large and small. As specialists in this field we are available to consult with your office to help you determine the best solution to your individual needs.