Self Pay Facts Sheet
Self-Pay refers to a payment category like Medicare or Anthem. When registering a patient in Athena, you must add a payer policy. When a patient does not have any insurance coverage or presents without enough insurance information to verify, they are assigned a payer policy of “Self-Pay”.
If a patient has insurance coverage, they are not “self-pay”. Due to contracts SMOC signs, as well as, state and federal regulations, we must follow a process before allowing a patient to bypass billing their insurance. It is simply not allowed for patients covered by Medicaid. Please review the FACT SHEET below and let your manager know if you have any questions.
What do contracts have to do with billing the patient?
When we are in network with an insurance plan, we have signed an agreement that we will bill services and abide by all plan limitations. If we do not follow the proper steps, we can lose our contract from that payer. Additionally, if the patient decides to submit the claim on their own behalf, we are still bound by the contract and must write of the balance unless it is proven that we followed process.
What’s the big deal if we are out of network, we do not have to abide by a contract?
SMOC will still need to follow a process. There is so much variability with benefits and billing, that the patient still needs to meet out of network deductibles and other costs. If we do not follow the proper billing guidelines we are doing a disservice to the patient.
What is the proper process?
An ABN should be obtained prior to the service being provided, regardless of network status. All ABN requirements should be followed.
Why can’t we make Medicaid self-pay if they or a family member wants to pay?
Medicaid is a “payer of last resort”. That means that the patient has gone through the state agency and been declared as not able to afford to pay for medical services. The state the patient resides in is responsible for paying for those medical services deemed necessary. Because SMOC is a participating provider with Virginia Medicaid, we are not allowed to bill the patient.
Cardinal Care is the Virginia Medicaid Plan. Medicaid requires all recipients of Medicaid to choose a managed care plan. Currently, we participate with UHC, Sentara and Anthem Cardinal Care plans. We cannot be paid for Cardinal Care Plans that are not through UHC, Sentara or Anthem.
SELF PAY vs PROMPT PAY DISCOUNT
SMOC has one fee schedule that everyone is billed regardless of the insurance or self-pay policy that is set up. We do not have a “self-pay” fee schedule. It is not allowed to bill different fees based on the payer assigned to the patient.
SMOC does offer a Prompt Pay Discount for those patients requesting to pay their large balance at the time of service with cash or credit card. This does not apply to those patients covered by in network insurance or to co-pays or deductibles. For convenience, we have listed Prompt Pay Discounts in an easy reference sheet for front desk to use.
Why can’t a patient that has in network insurance get a prompt pay discount?
An insurance plan that is in network with SMOC has discounts applied via the contract agreement signed.
What about services not covered?
When an in-network insurance does not cover a service or supply, an ABN is signed, AND the patient pays for the service on the same day received, a prompt pay discount can be given. The same is true for out-of-net network services.
