Medical Billing Forum

Payments => Insurance Payments => Topic started by: wharta on August 18, 2010, 08:52:45 AM

Title: Out of network billing
Post by: wharta on August 18, 2010, 08:52:45 AM
I have a doctor who does not have contracts with her bcbs. All her pts plans have payment whether in network or out of network so receiving payment will not be the issue.
She accepts assignment and has worked out a fee schedule with anthem on what they will pay her per charge.
Should we be balance billing the pts for the difference between what we charge and the allowed amount- balance bill, or should be be just taking what they pay us and writing of the rest?
Title: Re: Out of network billing
Post by: Michele on August 18, 2010, 01:27:37 PM
You should bill the patients for any difference in the amount paid and amount allowed. 
Title: Re: Out of network billing
Post by: PMRNC on August 18, 2010, 05:05:02 PM
Quote
I have a doctor who does not have contracts with her bcbs. All her pts plans have payment whether in network or out of network so receiving payment will not be the issue.
She accepts assignment and has worked out a fee schedule with anthem on what they will pay her per charge.
Should we be balance billing the pts for the difference between what we charge and the allowed amount- balance bill, or should be be just taking what they pay us and writing of the rest?

I'm confused because NON par providers will not receive the checks, as BCBS will not honor assignment for non contracted providers.
Title: Re: Out of network billing
Post by: medauthor on August 18, 2010, 07:37:24 PM
I, too, am confused because if she is "accepting assignment"; by definition, that would mean she is agreeing to accept what the payer pays as payment in full minus any deductible, co-payment, or co-insurance. 
Title: Re: Out of network billing
Post by: ellie on August 18, 2010, 08:40:02 PM
what is everyone's definition of balance bill the patient ?
Title: Re: Out of network billing
Post by: wharta on August 19, 2010, 08:41:06 AM
She has worked out with anthem what they will pay her, so since she does not have a contract, she should not accept assignment and balance bill? But if she does not accept assignment they probablyown't pay her, and if she does accept assignment she is to take what they pay as final payment and cannot balance bill- correct?
Title: Re: Out of network billing
Post by: PMRNC on August 19, 2010, 09:27:24 AM
It's still unclear because on one hand you said she's NON contracted..if they "negotiated fees" for that person ok, I understand..(usually they don't but ok ???)  If that's a negotiated fee for all her patients with Anthem..then she is contracted..I don't understand why they wouldn't have contract? Are you POSITIVE there is no contract? maybe they are telling you what they will pay at the NON contracted rate? Even Still BCBS is not going to honor assignment for a non contracted provider, the patient is going to get the check.

Also Michele is right..if the provider is agreeing to "accept assignment" she's agreeing to that fee as payment in full you can't balance bill the patient!  you need to call provider relations and find out if there's a contract or not.

Title: Re: Out of network billing
Post by: Michele on August 19, 2010, 09:43:45 AM
Balance Bill = bill the patient for whatever amount is indicated on the eob to be patient responsibility.   (unless provider is non par, then balance bill would be any remaining balance after insurance payment)
Title: Re: Out of network billing
Post by: wharta on August 19, 2010, 10:38:31 AM
Right, I believe she was referring to what they will pay at the non network rate, because she has no id number or anything from anthem. She set her fee schedule according to this amount also. So I should set her up as not accepting assignment, and balance bill remaining from the allowed amount?

I think that is correct :)
Title: Re: Out of network billing
Post by: Pay_My_Claims on August 27, 2010, 07:19:37 PM
It's still unclear because on one hand you said she's NON contracted..if they "negotiated fees" for that person ok, I understand..(usually they don't but ok ???)  If that's a negotiated fee for all her patients with Anthem..then she is contracted..I don't understand why they wouldn't have contract? Are you POSITIVE there is no contract? maybe they are telling you what they will pay at the NON contracted rate? Even Still BCBS is not going to honor assignment for a non contracted provider, the patient is going to get the check.

Also Michele is right..if the provider is agreeing to "accept assignment" she's agreeing to that fee as payment in full you can't balance bill the patient!  you need to call provider relations and find out if there's a contract or not.



We file BCBS assigned all the time, it really doesn't matter because BCBS does not send non par providers the check. Non-assigned would mean the payment needs to go to the client because they paid up front, so you have nothing else to choose but assigned. BCBS just does not honor that they expect you to collect up front knowing their policy. They want to get patients to go to par providers and this is a way they do it. You can still balance bill the patient for everything after payment. BCBS pays according to contract, but since you are non-par, you have the RIGHT to balance bill. Accept assignment rules would apply more to medicare than commercial payors
Title: Re: Out of network billing
Post by: PMRNC on August 27, 2010, 09:54:05 PM
Yes.. exactly my point Charlene.
Any monies due are going to the patient whether they paid or not..So I'm not sure even why the provider would bill according to their allowable when they are non par..they are losing money :(

Title: Re: Out of network billing
Post by: Pay_My_Claims on August 31, 2010, 01:54:29 PM
Yes.. exactly my point Charlene.
Any monies due are going to the patient whether they paid or not..So I'm not sure even why the provider would bill according to their allowable when they are non par..they are losing money :(



For Real.....something a biller should know to "help" increase revenue for a provider
Title: Re: Out of network billing
Post by: wharta on September 08, 2010, 05:54:36 AM
My provider does not want to balance bill, she is afraid that due to the amounts of claims- up to $10,000 per pt per month , that she will lose a lot of her pts.
Title: Re: Out of network billing
Post by: Pay_My_Claims on September 08, 2010, 07:30:25 AM
My provider does not want to balance bill, she is afraid that due to the amounts of claims- up to $10,000 per pt per month , that she will lose a lot of her pts.

So she would rather lose money.........they why not become a Par provider. It just don't make sense.
Title: Re: Out of network billing
Post by: PMRNC on September 12, 2010, 12:29:15 PM
Whether she pars or not, or wants to or not, or is afraid of losing patients, what she is doing is not right.
Title: Re: Out of network billing
Post by: midwifebiller on September 15, 2010, 08:14:05 PM
Many BCBS plans do send checks to a non-par provider.  We have billed for OON midwives in 32 states--most of them send the check to the midwife, not the member.
Title: Re: Out of network billing
Post by: PMRNC on September 16, 2010, 06:09:49 AM
They are not supposed to.. there are 6 states that have taken them to court and lost because they don't honor assignment of non par providers. I had a provider once that got his checks and upon research we found he had a contract he never canceled or opted out of.
Title: Re: Out of network billing
Post by: Betterway on September 25, 2010, 12:13:03 AM

I'm only familiar with Georgia where BC/BS will pay a non par provider who accepts assignment as long as the patient has a Georgia policy. If the patient has an out of state or federal policy, then the check will always go to the patient.