Question about no OV coverage

[jwangelin]

When a pt has no OV coverage, can you charge the pt the allowable amt from the insurance company, or do you have to charge the pt the full charge as in what you would charge the insurance company if they had OV coverage.   

[Michele]

I'm confused, if they have no coverage for OV's, why is there an allowed amount?

[PMRNC]

There are quite  few private plans or high deductible yield plans that don't cover office visits. But Yeah I agree with your question.. how can their be an allowable?

[Pay_My_Claims]

if you are in network with BCBS and one plan allows 125.00 for an OV, but your BCBS does not cover OV, then you can have an allowable. It will be adjusted as non-allowed benefit. Just because its not an allowed benefit does not mean its not an allowable. It will then become patient responsibility.

[PMRNC]

No, when something is considered a "NON" Covered benefit, there is no allowable. The allowable would be "0"
My sister has a quirky plan where she has tests and such covered but NO office visit coverage, I'm in middle of an appeal for her for something else but her EOB's show the allowable as 0 for office visits.  "Allowable" means allowable. Now it could be that they don't cover "routine" office visits with a diagnosis criteria in which case the allowable would be what they would "allow" if it were a covered diagnosis under their plan.

[Priyan]

Hi:

An simple solution for the subject is Yes You can Bill the PT for the amount what you charge INsurance, If PT requests for any discount you can go head with writeoff after Dr's concern.
No matter what the private insurance is because (Govt Insurance always allows visits)

But, this debate was quite good to help every one understand about the difference between what is allowable sevice and what is allowable amount.

Thanks for every one participated \ participating in this debate

[Pay_My_Claims]

No, when something is considered a "NON" Covered benefit, there is no allowable. The allowable would be "0"
My sister has a quirky plan where she has tests and such covered but NO office visit coverage, I'm in middle of an appeal for her for something else but her EOB's show the allowable as 0 for office visits.  "Allowable" means allowable. Now it could be that they don't cover "routine" office visits with a diagnosis criteria in which case the allowable would be what they would "allow" if it were a covered diagnosis under their plan.

thats not true. I have it on my EOB's all the time. I verify benefits every day. I can fax you over one of mines so it wont' be a violation. They will state billed 110, allowed 110, paid 0, and the denial is non covered benefit. This allows you to bill the patient.  BCBS pays for Office Visits, but lets say my plan doesn't cover that. Does this mean BCBS does not have an allowable or fee schedule??

[Anand]

No, when something is considered a "NON" Covered benefit, there is no allowable. The allowable would be "0"
My sister has a quirky plan where she has tests and such covered but NO office visit coverage, I'm in middle of an appeal for her for something else but her EOB's show the allowable as 0 for office visits.  "Allowable" means allowable. Now it could be that they don't cover "routine" office visits with a diagnosis criteria in which case the allowable would be what they would "allow" if it were a covered diagnosis under their plan.

thats not true. I have it on my EOB's all the time. I verify benefits every day. I can fax you over one of mines so it wont' be a violation. They will state billed 110, allowed 110, paid 0, and the denial is non covered benefit. This allows you to bill the patient.  BCBS pays for Office Visits, but lets say my plan doesn't cover that. Does this mean BCBS does not have an allowable or fee schedule??

I think Charlene is right because the claim denied as NON-Covered service under pt's plan and not non-covered under BC Fee schedule. The service is very much part of the fee schedule however pt's plan is not covering the service and the provider being par. I think its better we bill pt based on the EOB's

[Pay_My_Claims]

? @ Linda if it is a non-covered benefit, and the allowable shows what we billed as the allowed amount can we bill the patient?
Also if the allowable is zero, can we bill the patient?

I question this because of clients ability to refuse to sign financial statements which state if your ins denies for non coverage , you will be responsible.  I totally get what you are saying, i think the question comes in how the carrier codes the EOB's

[PMRNC]

Yes, you can definitely bill the patient, but you can bill them up to the physicians fee, A carrier cannot "allow" something, deny it as NON covered and expect the doctor to only collect what they WOULD have allowed? The doctor should be able to collect THEIR full fee. I have a few clients with BCBS private insurance and some of the high yield deductible plans only cover diagnostic testing, no office visits and the allowable shows $0 

[Pay_My_Claims]

Yes, you can definitely bill the patient, but you can bill them up to the physicians fee, A carrier cannot "allow" something, deny it as NON covered and expect the doctor to only collect what they WOULD have allowed? The doctor should be able to collect THEIR full fee. I have a few clients with BCBS private insurance and some of the high yield deductible plans only cover diagnostic testing, no office visits and the allowable shows $0 

thanks!!