Health Assets
The Answer for Mental Health Practices in New York State


Health assets Mental Health Billing Forms and Resources

Out Of Network Claims


Since many more Health Plans are no longer offering out of network benefits, we thought you might want a refresher on the various situations that can arise with your patients’ benefits.

 If you have a contract with a payer, you must accept the allowed fee as the full payment for your services.  This fee may include a patient copay.  You cannot “balance bill” the patient beyond the allowed amount associated with your contract.

 If you are not under contract with the payer, you are “out of network”.

 Some patients may have out of network benefits, which will be paid to you or the patient. You may balance bill the patient to receive compensation equaling your established standard fee.

 New York State has issued a reminder to all practitioners to be sure that they have established a standard fee for each service (CPT code).  You are expected to bill private patients and all health plans according to your standard fee. (Of course, if you have a contract with a payer, they will, instead, pay the amount indicated in your contract.) If there is a reason that you feel it would be necessary to reduce the amount a patient pays for a service, you may reduce the amount you will accept for the patient.  This should be done with serious consideration and the reason for the reduction should be documented.

 Out of network claims should be submitted to the payer, even if you have made a private arrangement with the patient.  There are a number of reasons why this is the best choice.  First, if the patient has out of network benefits, the patient may have a deductible and all claims will apply to the deductible amount.  Second, the patient may have an HSA account which would give them the funds to pay you.  After the claim is submitted the patient will receive the remittance advice which will be used to release the funds for your payment.  Another situation involves secondary insurance coverage.  The claim must be submitted to the primary insurance (where you are out of network) in order to have the secondary claims processed.  Additionally, if the patient’s plan changes or your in-network status changes, the insurance plan may pay you for this claim.

 If you are a current Health Assets customer, please reach out to Alison Schenck aschenck@healthassets.com or Brett Jones bjones@healthassets.com if you have any questions or concerns regarding your established fee schedule.

 If you are not yet a Health Assets customer, feel free to email or call for more information on how we can help you and your practice.

 As always, we are available to assist with any practice management matters.

All my best,

Carmel

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