Author Topic: Allowed Amount  (Read 1680 times)

kittykat

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Allowed Amount
« on: October 31, 2016, 01:37:03 PM »
I am trying to understand something that is probably really simple and that is the allowed amount. I do understand that that will be all the insurance will pay. But let me give you a scenerio and see if someone can help me make sense of this.

This is in inpatient residential facility that cost $30,000 for 30 days. The lady with the insurance told me that they will cover up to the allowed amount then after that the facility can write the rest off since they are in network with them. So I guess what I am trying to understand is if the allowed amount is only $5,000 and the patient will owe their portion of lets say $5,000 is the facility out the rest of that money?

Also, the insurance lady told me she could not tell me the allowed amount. So I just bill for whatever and then they will send a check for the allowed amount? That doesn't seem right to me. Or could they at least not tell me what that number will be? And does the facility have to write it off or could the rest of the money not fall onto the patient?

As you can see I am a little confused haha if someone could help me I would really appreciate it!

kristin

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Re: Allowed Amount
« Reply #1 on: October 31, 2016, 08:09:00 PM »
If the facility is contracted as in-network with the insurance, then they agree to accept the fee schedule the insurance has for their services. You can request a copy of that fee schedule, so that you set your fees appropriately. So, if for a 30 day stay the insurance allows $5,000, and they pay their portion of that $5,000, then all that can be billed to the patient is the difference between what is allowed, and what insurance paid. Anything beyond that is a provider write-off, for being over the allowed amount.

Michele

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Re: Allowed Amount
« Reply #2 on: November 01, 2016, 07:16:09 AM »

Also, the insurance lady told me she could not tell me the allowed amount. So I just bill for whatever and then they will send a check for the allowed amount? That doesn't seem right to me. Or could they at least not tell me what that number will be? And does the facility have to write it off or could the rest of the money not fall onto the patient?


When the facility enrolled to be in network with the insurance they should have been given the fee schedule at that time.  Usually a facility would see what the allowed amounts are prior to enrolling to make sure they are ok with the allowed amounts.  But like Kristin said you can request a copy of it now if you don't have that original copy.
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PMRNC

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Re: Allowed Amount
« Reply #3 on: November 01, 2016, 11:06:42 AM »
If they are telling you they can't give you a fee schedule it is because if you were in network you should have the fee schedule with your contract. If you are not contracted with the carrier than it's not "allowable" but in fact Reasonable & Customary (R&C) or Usual & Customary (U&C). If you are non contracted you may bill the patient for any balance above U&C or R&C, but if you are participating with a contract, you can only bill the patient up to the allowable amount.

Linda Walker
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kittykat

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Re: Allowed Amount
« Reply #4 on: November 01, 2016, 12:42:00 PM »
OK thanks everyone this is a lot of help. I will ask the facility owner to look up her contract and see what it says. Thank you!

PMRNC

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Re: Allowed Amount
« Reply #5 on: November 01, 2016, 01:19:32 PM »
Are you the biller? If so you might want to have access to contracts and fee-schedules rather than have the facility owner or physicians look it up, they rarely know which end is up. If you are doing the billing, you really should have access to all plan contracts and fee schedules.
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kittykat

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Re: Allowed Amount
« Reply #6 on: November 02, 2016, 11:51:47 AM »
They want me to eventually bill for them but I don't know much about it yet but this was a problem they ran into the other day and didn't know what to do. They had a biller who just walked out one day so they are scrambling.

One other question. If they are out of network how would we know the allowed amount? Since they don't have a contract and the ladies I talked to at the insurance company said they don't have that information. Is there somewhere I can find it myself?

PMRNC

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Re: Allowed Amount
« Reply #7 on: November 02, 2016, 12:08:28 PM »
If they are not contracted that means fees are subject to U&C / R&C (Usual or Reasonable & Customary). Carriers don't give out that info. If you call to verify benefits you can ask them if your fee is within U&C but they will not give out the U&C. If your office does high dollar value services it might be beneficial to submit a pre-determination of benefits to carriers your not contracted with.
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Michele

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Re: Allowed Amount
« Reply #8 on: November 03, 2016, 07:40:28 AM »
If they are out of network how would we know the allowed amount?

If they are out of network they really don't need to know the allowed amount do they?  They would bill their regular fees.  Payment is most likely going directly to the patient in that case.

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PMRNC

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Re: Allowed Amount
« Reply #9 on: November 03, 2016, 08:09:48 AM »
Quote
If they are out of network they really don't need to know the allowed amount do they?  They would bill their regular fees.  Payment is most likely going directly to the patient in that case.

The patient might like to know. With my ped's we do a pre-deterrmination of benefits for certain procedures. We provide the carrier with the CPT, anticipated fee and they tell us Yes or no it's within U&C. This of course is for non-contracted providers. This way we can advise the patient that there will be some out of pocket. The carrier won't tell us the U&C amount but they will tell us if our fee is within U&C. We do this for high dollar procedures.
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sujana

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Re: Allowed Amount
« Reply #10 on: December 09, 2016, 11:25:21 AM »
Every Bill should consist of a Procedure code /CPT code and it will be linked to a fee schedule of that particular insurance. We may have to look in to the CPT to link to the Fee schedule for that particular Year (Date of service billed).