MRA Thought of the Day- HIPAA Compliance: Self Pay Services

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Karen Gallagher Grant RHIA, CHP

Karen Gallagher Grant


Karen Gallagher Grant, RHIA, CHP
Karen Gallagher Grant, RHIA, CHP

A patient arrives for her annual dermatology exam and decides to have some cosmetic surgery done. She calls two days later indicating she would like to pay cash for the procedure but would like the provider to bill her insurance company for the annual dermatology exam.

Here are my thoughts…

Assess the situation with these seven steps:

  • The final rule requires a provider to comply with an individual’s request for a restriction on the disclosure of PHI that pertains solely to a health care team or service for which the provider has been paid in full out of pocket by the individual or another person other than a health plan.
  • If the individual requests the restriction, the provider cannot disclose the PHI to a health plan for payment or healthcare operations
  • There is an exception for disclosure required by law (government health plans)
  • If both covered and self-pay services are provided in one encounter, the restriction applies only to the self-pay services and not the covered services.
  • A provider who provides an out of pocket service is not obligated to notify other providers of the requested restriction.
  • A contractual ban on balance billing or a hold harmless clause in a managed care agreement does not override this right. Patients may need to be counseled to get self-pay services out of the network.
  • Provider need not honor the restriction if it is requested after care had been delivered.

What are your thoughts?

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