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Fam Pract Manag. 2005 Jun;12(6):64.

Insurers must come clean to get medical records

Q

I received a letter from an insurance company requesting complete copies of certain medical records. They did not give a reason, but their investigator said it is routine. How should I respond?

Under federal privacy rules, unless the record is for treatment purposes, physicians should only provide the minimum amount of information to honor the request. By not knowing the nature of the request, you cannot determine what is minimally necessary. Privacy rules do not prohibit the use, disclosure or request of an entire medical record if the practice has documented in its policies and procedures that the entire record is the amount reasonably necessary for certain identified purposes, but your policy would have to identify those purposes.

You have not indicated what type of insurer made the request. The situation will vary depending on whether the request is from the patient's health insurance company, a worker's compensation insurer or a liability insurer. This may be “routine” for the insurer, but they have not provided enough information for a physician's purposes. You should request clarification.

How to handle health savings accounts (HSAs)

Q

A patient presented our biller with his member ID card and referred to it as an HSA. How should we calculate and collect what the patient owes?

HSAs were created under the Medicare Modernization Act of 2003. They are personal savings accounts that provide a tax-free method of saving for qualified medical expenses. An HSA is linked to a High Deductible Health Plan (HDHP), which is a health insurance policy that has a higher annual deductible than typical health plans and has a maximum limit on the annual out-of-pocket medical expenses that the employee must pay for covered expenses.

Physicians who are under contract with a payer who sells HDHPs are obligated to accept the contracted fee-for-service payment for services rendered to patients with HDHPs. Balance billing for covered services is not permissible.

Under these plans, some payers prohibit or discourage collection of patient fees at the time of service. In these cases, you'll have to file a claim and wait for the Explanation of Provider Payment to determine how much the patient owes. Collecting patient payments after the time of service is always more challenging and time consuming, and it could lead to higher administrative costs and bad debt expenses. My advice is to know your contracts and what amount, if any, can be collected at the time of service. It would also be good to ensure that your practice can accept debit and credit card payments to facilitate your billing and collection efforts.

The Internet provides resources for learning more about HSAs. To learn more about how these plans work, visit http://www.ehealthlink.com/hsa.asp and http://www.irs.gov/publications/p969/index.html.

Social Security number not always necessary, but helpful

Q

Our practice has several patients who refuse to disclose their Social Security number (SSN). This makes it difficult for us to collect from their insurance companies. What are our legal rights in this area?

The first thing you should consider is whether the payer requires a SSN. Some do, and some – like Medicare – don't. Even if you think you know the answer, write the payer and ask whether a SSN is required and whether the payer will reject the claim without it. Be sure to request a written response. Your patient registration forms should ask for a SSN. Remember, however, that a SSN is highly sensitive and you have an obligation to keep it secure. If a new patient whose plan requires a SSN refuses to provide one, showing a copy of the health plan's response may be enough to persuade him or her to cooperate.

If you've already provided the service, you may be able to bill the patient directly for it. Your participation agreement with the payer probably doesn't address this type of situation specifically, but it should explain that you can bill patients directly for services the plan determines it won't pay for but that the patient receives anyway. This is essentially what's happening in your case.

If the patient won't pay you what is owed and won't provide a SSN so that you can be reimbursed by the health plan, you can dismiss him or her from your practice. Be sure to consult your contract and the plan, if necessary, to ensure that you follow the correct termination procedures.


* Denotes member of FP Assist, the AAFP's online clearinghouse for consultants and attorneys.


 

Copyright © 2005 by the American Academy of Family Physicians.
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