Author Topic: out of network  (Read 1633 times)

ellie

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out of network
« on: January 20, 2011, 07:30:14 PM »
patient has two out of network plans - he has a large balance due. We balanced billed him the remaining balance after his insurance payed the out of network rate. We can discount some money if we want ??

PMRNC

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Re: out of network
« Reply #1 on: January 20, 2011, 08:30:44 PM »
No, not after the fact. The logic being that the insurance carrier would be paying on a different amount. For example if the patient has a $100 out of pocket balance due on a $500 charge billed to the insurance, if you discount, say $50.00 then there has been a breach of contract between the patient and the insurance company because they too should have the opportunity to pay the charge based on the discounted fee ($450, using my example).  That's ONE issue. The other issue is the Anti-kickback statute which says "doctors may not routinely waive copay's and out of pocket....etc etc" The concept being that IF you know in advance there is a hardship, then a hardship agreement should be in place and again it cannot be done "routinely".

Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

tlewis

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Re: out of network
« Reply #2 on: January 26, 2011, 10:44:39 AM »
It depends on how the out of network plan paid. If they only paid on what they demmed  to be "usual and customary" you don not have to bill the patient for the non "usual and customary portion" you would still have to bill for the deduct and co-pay on the "usual and customary".
example
billed $500
Insurance claimed that $300 was usual and customary pt had $100 deduct and they paid the rest at 50%=$100
states remaining charges as $400
You don't have to charge the extra $200 you can except the "usual and customary and not charge for the $200 that the insurance didn't include in their payment.
so pt balance would be $200

PMRNC

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Re: out of network
« Reply #3 on: January 26, 2011, 10:47:52 AM »
Quote
It depends on how the out of network plan paid. If they only paid on what they demmed  to be "usual and customary" you don not have to bill the patient for the non "usual and customary portion"

Excellent point.. :)
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

tlewis

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Re: out of network
« Reply #4 on: January 26, 2011, 11:01:49 AM »
also if the balance is rather large and you have sent the patient at least 3 statements and the patient states that he is unable to pay the large amount owed. You can discount the balance. You are a place of buisness and have the right to collect what you can for services. so lets say the balance is $5000.00 and the patients states that they can only afford $2500.00 you can accept that as pd in full. However make sure you have sent out at least 3 statements before accepting a lessor amount.