Payments > Patient Billing

Benefit misquote = tough situation =advice needed

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Sorry for the tough situation to your office and the patient. Our offices have a standard form that all patients sign acknowledging that benefits quoted are not a guarantee of benefits. It also explains that once a claim has been submitted to the insurance company, any coinsurance, copay, or deductible applied is the patient's responsibility. If the patient does not want our office to submit the claim to the insurance company, they must agree to be a self-pay patient. However, if the patient does not agree with how the claim was processed, we encourage the patient to submit a formal reconsideration or appeal to their insurance company. We also have submitted appeals on the patient's behalf challenging the insurance's processing of the claim.

We had a similar issue with a payer processing the E/M with a copay as well as the in-office procedure. The patients were obviously upset by that and we agreed with their frustration. After in-depth research with the insurance's provider rep we found out that the claims were in fact misquoted and processed incorrectly. In our case, because the in-office procedures were processed according to the patient's surgical policy, any in office procedure (such as a nasal endoscopy 31231 or cerumen removal 69210) was subject to the surgical copay plus the office copay. For some policy's the surgical copay was $200. Some in-office procedures have an allowable that is $320+ so you can probably understand why patients were easily angered by this. We were able to have the surgical copays paid by the insurance company but it was not completed without submitting appeals.

Regardless of what is quoted from the insurance rep or the benefits obtained online, if a claim is processed towards patient's deductible or coinsurance we have agreed to set up payment plans for the patient. Most of our physicians have agreed to financial hardship discounts if the patients were willing to pay the balance in full at the further discounted rate.

The best thing you can do for yourself as a practice and for the patient is to educate them on the importance of checking benefits with their insurance before any procedure is completed; including providing the patient with possible CPT codes, and diagnosis codes that could be billed.  Also, having the patient sign an acknowledgement that any benefits quoted by the insurance are not a guarantee of payment and that final determination cannot be made until the claim has been processed by the insurance is also a safeguard.

If for any reason, we are aware that the patient's deductible, out of pocket max has not been met, or coins may apply we can collect up to the contracted allowable amount from the patient at the time of service or at check out (once they've signed the procedure consent form) and advise that once the claim has been processed and the EOB received, we can refund the patient any overpayments, should one exist. We run monthly overpayment reports and refund patients any overpayment every month. Collecting up front can avoid issues like angry patients and surprise bills. If the patient cannot afford the cost of the contracted rate, our office managers or providers work with the patient, and either agree to a partial payment until the claim has been processed or reschedule the procedure for another day. However, the physicians would rather avoid a delay in treatment and opt for a partial payment.


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