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Law Educator, Esq.
Law Educator, Esq., Attorney
Category: Legal
Satisfied Customers: 117370
Experience:  JA Mentor -Attorney Labor/employment, corporate, sports law, admiralty/maritime and civil rights law
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A tricare patient wants to be self pay. Tricare says we have

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A tricare patient wants to be self pay. Tricare says we have to accept Tricare rates which are deemed too low to be acceptable and we do not allow them to be treated as self pay in our surgery center. Is this allowable under the new HIPAA guidelines that allow self pay when covered by insurance for purpose of record restriction? There seems to be two issues..what are our rights to say no self pay to a patient because of contractual low rates and is a patient able to become self pay for surgery only if used insurance for office visits determining need for surgery?
Thank you for your question. I look forward to working with you to provide you the information you are seeking.

Unfortunately, while your patient can self pay under HIPAA and you can charge at outside the Tricare rates because for that surgery she is not a Tricare patient, the problem is for the HIPAA rule on self pay that allows her to restrict her records, once she goes self pay for the surgery you would have to make all of her visits related to that surgery self pay because to not do so defeats the record restriction as Tricare would then get the information on the surgery follow up. However, she can self pay for surgery if she chooses and if she does not file the surgery claim with Tricare then you are not bound by the Tricare rates for the surgery only and as long as she is not worried about the restriction on the medical records to the insurer she can do this.

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Customer: replied 3 years ago.

What about the Dept of Defense Appropriations Act of 1993 that limits the fee amount a provider that does not take assignment may bill to a percent of Tricare maximum allowable? Our self pay rates are higher. Do we charge our rate or the tricare allowable in this instance?

If she is not going through her insurance on the surgery the act would not apply on the surgery the way I read the act that is the issue.
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