Billing > Billing

Discounting a Non-Covered Service to a pt that has insurance

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Pay_My_Claims:
Well the question would be is the discount higher or lower than the allowable that Anthem is allowing. According to what he posted. The Anthem coverage they have doesn't cover office visits, but Anthem does have an allowable for one. IE: they bill 45.00 client has no coverage 100% responsible, but Anthem's allowable is only 30.00. They want to bill the client more or less than Anthem's allowable is that ok? Anthem states they can bill 30.00 since they are par providers they can't charge more than the allowable. If they prompt pay 25.00 ok, they are adjusting off 5. if they prompt pay 35.00 no, they are charging the client more than the contracted allowable rate per Anthem.

Michele:
The question states "discount the fee even further" so they mean lower than the anthem allowable. 

I've actually seen eobs with this scenario.  They process the charge, show the billed amount show the allowed amount, show copay $0, ded $0, pd $0, pt responsibility $(allowed amount). 

I thought as long as they billed the allowed amount, but then offered a prompt pay discount they would be ok. 

Boy, this one certainly prompted some healthy discussion!   :)

Michele

PMRNC:
I couldn't see in his/her post where there was an allowable amount given to us.. if the PLAN is just catastrophic or hospitalization there won't be a fee schedule for Major Medical charges, you can't have an allowable fee when there is no coverage, again we don't know for sure. 

Pay_My_Claims:
There wasn't an allowed amount given, it was just used as an example.

Scenario: I have BCBS of NC PPO. My plan does not cover for a gyn exam. My girlfriend also has a BCBS of NC PPO policy,but hers does. The gyn exam is an exclusion on my plan, but does not mean BCBS of NC does not cover gyn exams, just means on my plan it will not cover. When I see my pcp and have a gyn exam I have to pay out of pocket since it is non-covered. If BCBS of NC didn't cover at all any gyn exams, then I would be 100% liable, and the entire fee would drop to me. Since BCBS does have an allowable, it is just non-covered by my plan, BCBS sends the claim back with an "allowed" amount, and that is the max they can charge me. This is what I feel the poster is speaking of. If he knows the office visit isn't covered, he can tell them they don't have that benefit, and will be responsible per Anthem guidelines for XX.xx, but if they pay today they can pay XX.xx (lower than the allowed amount). If he is prompt paying them more than the allowed by saying we charge XXX.xx and its non covered by your insurance, but if you pay XXX.xx  (more than Anthem allows) then he is over charging the patient and can not since he is a par-provider. Just because their plan doesn't cover the visit doesn't mean he can bill more than the allowed.

Pay_My_Claims:

--- Quote from: Michele on June 07, 2009, 09:04:43 AM ---The question states "discount the fee even further" so they mean lower than the anthem allowable. 

Michele

--- End quote ---

he could also mean discount their fee lower which is more likely what most providers will want to do. They usually don't want to drop it lower than what the insurance company allows.

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