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Patient Election to Self-Pay - When It’s OK and When It’s Not!

Learn the the exact self-pay process you need in your practice to stay compliant, both with Medicare and commercial insurers.

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The HITECH-HIPAA Omnibus Rule, effective September 23, 2013, requires that “a covered entity must agree to the request of an individual to restrict disclosure of protected health information about the individual to a health plan if the disclosure is for the purposes of carrying out payment or health care operations and not otherwise required by law; and the protected health information pertains solely to a health care item or service for which the individual, or person other than the health plan on behalf of the individual, has paid the covered entity in full.”

This means that there may be times when a patient can direct you NOT to bill their insurance, electing to pay cash instead. Perhaps they have a high deductible, a large per-visit copayment, or other circumstance that dictates electing to self-pay. Some have seen this as a way to see Medicare patients without enrolling in Medicare. Chiropractors may not “opt out” of Medicare. In order to treat a Medicare patient, the letter of the law requires that you are enrolled and “equipped” to bill Medicare on behalf of the patient. This is the rule regardless of whether you render a covered service (adjustment) or a service that is never covered (exams, x-rays, therapies). You must be able to bill and receive payment or a denial on your patients’ behalf.

  • How the HIPAA Omnibus changes of September, 2013 gave your patient unprecedented rights
  • The exact documentation necessary in order to allow them to invoke those rights
  • The contractual language to look for in your provider agreements to stay on the right side of the rules

Patient Election to Self-Pay - When It’s OK and When It’s Not! Implementation Guide

Fact Sheets:

  • Restriction of PHI - Election to Self-Pay
  • Restriction of PHI – Not a Work-Around

Quick Byte Concept:

  • Patient Election to Self-Pay - When It’s OK and When It’s Not!

Support Tool:

  • Restriction of PHI/Election to Self-Pay Writable
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