Medical Billing Forum

General Category => General Questions => Topic started by: laurahartman on April 16, 2012, 03:48:48 PM

Title: Typcial Process for InNetwork Provider but Specific Procedure not covered
Post by: laurahartman on April 16, 2012, 03:48:48 PM
Hello,

I'm working on a project with a Dermatologists office to standardize process and procedures and have a question for the experts on this message board related to billing and insurance payment.

In the case where the Dr is In-Network for a specific patient, but one of the procedures does not pay as insurance decided "not medically necessary". What is the amount the patient is then billed and responsible for?
1. Billed amount
2. Contracted amount for the procedure code (although not covered for this specific patient)
3. Some other amount

Thanks so much and I really like this forum, I'm new and have been on the website reading posts the last few hours!
Laura
Title: Re: Typcial Process for InNetwork Provider but Specific Procedure not covered
Post by: Michele on April 16, 2012, 07:31:06 PM
It depends on the provider's contract with the insurance carrier.  The contract may state that the provider cannot bill the patient for the disallowed service.  The eob should state what the patient responsibility is and that is what the patient can be billed.

Glad you are enjoying, that is what it is for!