Author Topic: Balance Billing Clarification  (Read 987 times)

PippiT

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Balance Billing Clarification
« on: February 21, 2016, 05:38:02 PM »
Can someone tell me if this is legal?

We have a financial agreement on file for each patient that has been signed indicating that anything their insurance does not cover or pay for it is the patients responsibility to pay.

We are on a prepayment audit for an arm of one of the insurance giants that we only have a couple of patients with that insurance so it's been going on forever. Every single claim we get a request for medical records. We submit the medical records and for every single claim they pay everything except one procedure code. Our notes are very detailed and backup every procedure code and I have appeals out but expect they will be denied.

My provider wants me to bill the patients. Which I do, but one patient called the insurance and they called me on 3 way and said there is no patient responsibility and we cannot bill the patient. It is a covered service that they just won't pay.

I was told from provider relations that it is balance billing and it is a violation of our contract and that the patient could get legal involved. I told them we had a financial agreement and they told me that their contract trumps our agreement. My provider says they are violating the contract by not paying covered services and that I must bill the patient and that he is covered by attorney's with financial agreement that we have in place.

The patient will not pay. Insurance has told them they have no responsibility so my next step is when we get the denials from the appeals to take the patient to small claims court.

I am still green in this career and I just don't know what is right or wrong in this situation.

Thanks in advance.

Michele

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Re: Balance Billing Clarification
« Reply #1 on: February 21, 2016, 08:16:20 PM »
If the provider is in network with that carrier then you need to look at the contract.  Most likely the provider agreed not to bill the patient for services that the insurance carrier deems not medically necessary, or whatever they are stating on that one procedure.  The provider most likely agreed not to bill the patient for anything other than what the insurance carrier specifies as patient responsibility.  So the shore answer is "yes".  If the provider signed a contract which is a legal document stating they would not charge the patient then it is legal.
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PMRNC

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Re: Balance Billing Clarification
« Reply #2 on: February 28, 2016, 08:07:05 PM »
Quote
We have a financial agreement on file for each patient that has been signed indicating that anything their insurance does not cover or pay for it is the patients responsibility to pay.

I hope your financial policy includes specific verbiage to account for contracts the provider participates (contracts) with as you may not just arbitrarily bill patients for balances if you are contracted.

We are on a prepayment audit for an arm of one of the insurance giants that we only have a couple of patients with that insurance so it's been going on forever. Every single claim we get a request for medical records. We submit the medical records and for every single claim they pay everything except one procedure code. Our notes are very detailed and backup every procedure code and I have appeals out but expect they will be denied.

My provider wants me to bill the patients. Which I do, but one patient called the insurance and they called me on 3 way and said there is no patient responsibility and we cannot bill the patient. It is a covered service that they just won't pay.

Quote
I was told from provider relations that it is balance billing and it is a violation of our contract and that the patient could get legal involved. I told them we had a financial agreement and they told me that their contract trumps our agreement. My provider says they are violating the contract by not paying covered services and that I must bill the patient and that he is covered by attorney's with financial agreement that we have in place.

Your provider is wrong and now that you know this, please protect yourself as you are now culpable. YOU also don't SPECIFY the services nor reason it was denied/non covered.

Quote
The patient will not pay. Insurance has told them they have no responsibility so my next step is when we get the denials from the appeals to take the patient to small claims court.

Your patient is right.. why should they pay, there was a blatant disregard for the physician/provider contract.


Quote
I am still green in this career and I just don't know what is right or wrong in this situation.


I'm about to give you the best advice you might ever receive.. There is no such thing as "ignorance" being an excuse in the world of medical billing. IF You know it's not right, if you suspect it is not right and if YOU SHOULD know it's not right, you are then culpable in anything being billed out.

In your post you never indicated any specific denial, but most of us will tell you that if the provider is participating with the carrier, WHAT they bill the patient SURE indeed does depend on the contract. So you have two ways to make this right and cover yourself. 1) check the denial to see if you have any valid appeal of the claim, check for all par adjustments and patient out of pocket. Note the reason for any non-covered, note the amount "allowed".   Take it from there.. you do not provide ENOUGH info to really give you the best advice with the exception of your provider saying they can balance bill .. that's a blanket statement that could  both you and them in great jeopardy.
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