Ask the Experts: Cost Sharing Programs

I am seeing a rise in patients thinking they are covered by health insurance but are really part of a cost sharing program, often religiously based. Once the claim is filed, a claims management company comes back with a payment of slightly more than Medicare (no contract is involved), call it fair and reasonable, call the additional charges excess, and in small print, state that cashing the check represents acceptance of their terms. I am looking for more information about how to manage these situations.

Answer: If the entity in question does not have a contract with the insurance company and has not agreed to a single-case agreement, they are entitled to charges. For years, we have stamped our checks with the phrase “all rights reserved.” This entitles us to pursue any outstanding balances and negates the notation on the check that it is payment in full. We’re located in New York. I’m unsure what the requirements are in other states, but I am sure that there are options in most situations that are similar to what we use.

This question was answered by: Kelly McGinnis, FHFMA, director of revenue cycle, HealthAlliance of the Hudson Valley, and a member of HFMA’s Hudson Valley NY Chapter.

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