Billing Scenario

[melissa_2004]

Hi guys,

Need some input for the below scenario:

Patient visits specialist and has insurance but believes insurance will only pay towards deductible.

She explains she cannot afford the full cost of the procedure ($575). 

Specialist gives a hardship allowance and charges patients $150.  Patient paid at time of service. 

Claim was submitted to insurance for procedure to be applied toward deductible. 

The insurance company allowed $105.30 for the procedure and paid $73.71 leaving a deductible amount of $31.59 for the patient to pay. 

Since the patient paid $150 but the insurance actually paid $73.71.  Should we not just deduct the $31.59 from the $150 the patient paid and refund the patient $118.41 for overpayment?

Not sure why the office charged her upfront instead of waiting for the EOB from the insurance carrier so we could send her a statement with the true amount owed.  That question is still outstanding.

[PMRNC]

You really don't say what exactly was billed. If you billed $575 and did NOT show the discount, that's a big no no.
Did the patient complete any type of financial hardship agreement? If not that's another mistake

Either way, the patient is responsible for all deductibles and coinsurance as it is the "COST sharing" provision of their policy. This is quite a pickle because if YOU AGAIN waive deductible it's wrong.. If you violate whatever agreement you had with the patient it's another problem. I think if this was something "I" billed out, and I made no agreement with the patient in writing (financial hardship) I would REBILL the claim correctly using the correct charge amount and showing the $150.00 payment and then speak with the patient and it would still be ok to discount the out - of - pocket as long as their is some sort of financial hardship agreement signed and noted in patient's chart.  JMO

[Pay_My_Claims]

i'm confused....did you bill out 575, and the ins company only allowed 105.00??  if this is the case and you are a contracted provider, then yes you owe the client all but what she should have paid for the deductible. Nothing else matters.

the way i read it, patient says she has not met deductible, procedure is 575 provider charge. provider says to client ok, i will bill your ins, and charge you 150 plus what they pay. and waive the balance. you bill case 575, but ins company only allows 105. and paid 70 30 goes to deductible. had not the hardship factor been involved, client would have only paid the 30....who verified the benefits and checked on her deductible status??? We must remember, no matter what we bill, contracted providers can only bill patients what is allowed. if the agreement wasn't made. the provider would have to refund the patient. if she collected it up front (client not met ded), once the ins pays, and it only allowed 105, provider must refund.

[melissa_2004]

You really don't say what exactly was billed. If you billed $575 and did NOT show the discount, that's a big no no.
Did the patient complete any type of financial hardship agreement? If not that's another mistake

Either way, the patient is responsible for all deductibles and coinsurance as it is the "COST sharing" provision of their policy. This is quite a pickle because if YOU AGAIN waive deductible it's wrong.. If you violate whatever agreement you had with the patient it's another problem. I think if this was something "I" billed out, and I made no agreement with the patient in writing (financial hardship) I would REBILL the claim correctly using the correct charge amount and showing the $150.00 payment and then speak with the patient and it would still be ok to discount the out - of - pocket as long as their is some sort of financial hardship agreement signed and noted in patient's chart.  JMO

OK here's more information.  The daysheet was provided but did not indicate the patient paid at time of service because she thought her insurance would go toward her deductible or about a financial hardship.  It was billed as normal.  The information about the hardship and the office payment did not come to light until the patient questioned receiving a statement to pay her balance of $31.59. 

I've questioned the office about a 'written' financial agreement with the patient but have not received that answer yet.  I have requested the office to allowed me to do the eligibility (part of their front desk person job right now).  At the very least, it would be a lot easier to bill the insurance, wait for the EOB and take it from there but that did not happen here.  I also asked the doctor for a meeting with the office so we can all get on one page about financial hardships for patients with insurance.  Our conversations in the past about it was only related to self pay patients.

i'm confused....did you bill out 575, and the ins company only allowed 105.00??  if this is the case and you are a contracted provider, then yes you owe the client all but what she should have paid for the deductible. Nothing else matters.

the way i read it, patient says she has not met deductible, procedure is 575 provider charge. provider says to client ok, i will bill your ins, and charge you 150 plus what they pay. and waive the balance. you bill case 575, but ins company only allows 105. and paid 70 30 goes to deductible. had not the hardship factor been involved, client would have only paid the 30....who verified the benefits and checked on her deductible status??? We must remember, no matter what we bill, contracted providers can only bill patients what is allowed. if the agreement wasn't made. the provider would have to refund the patient. if she collected it up front (client not met ded), once the ins pays, and it only allowed 105, provider must refund.

Charlene, I agree that a refund is in order.  According to the info I have so far the doctor also didn't know the insurance would pay but we dont bill this way just on a whim so I am now having other concerns with what may be happening in the office with other patients billing.  Its hard to think this is a isolated incidence when no one else sees a problem with this but me. 

[PMRNC]

You say it was billed as normal, so I'm only left to assume you charged full fee. Without looking at the EOB we still really can't see all the information, but I will assume a good portion went to deductible? Can you post the EOB details so we can see the allowable, the adjustments and deductible/patient responsibility..that might clear it up right there.

[melissa_2004]

Yes billed as normal.  Fee of $575.  EOB information below:

Billed= 575.00   
Allowed = 105.30
Applied to deductible = 0.00
Co-Ins = 31.59
Paid = 73.71
Adjust Amt = 469.70
Patient Balance = 31.59

[Pay_My_Claims]

Yes billed as normal.  Fee of $575.  EOB information below:

Billed= 575.00   
Allowed = 105.30
Applied to deductible = 0.00
Co-Ins = 31.59
Paid = 73.71
Adjust Amt = 469.70
Patient Balance = 31.59

You owe the patient!!

[melissa_2004]

My thoughts exactly but now the saga continues.  The office now wants to re-bill (send a corrected claim) to the insurance carrier at the discounted amount.  Still no confirmation on  a hardship agreement (written) with the patient.  I've requested a copy for my records.

[PMRNC]

My thoughts exactly but now the saga continues.  The office now wants to re-bill (send a corrected claim) to the insurance carrier at the discounted amount.  Still no confirmation on  a hardship agreement (written) with the patient.  I've requested a copy for my records.

NO can do and this should teach them a lesson!  There is no corrected claim..you billed your normal fee, though I must say that carriers allowance Bites!  Refund the patient. If you send a claim, the only difference is going to be you are going to show what patient paid, and it isn't going to matter, you are still going to owe the patient.

[melissa_2004]

Thanks for the input!  It was tough standing my ground with this but the point has gotten across.

Linda,  I agree the allowance really sucks.  Seems that way for a majority of the carriers this office is par with.  The range for reimbursement is $169 and lower for a $575 fee. 

[DMK]

That's why the docs have to keep the billed amount up.  If they lower it, then the U&C is lower, and the contracted rate will lower.  I always tell people it doesn't matter what the doctor bills, the insurance company tells them what they get!