This is a great website! I am desperately trying to find a definitive answer to my billing question, and I think this is the place.
I bill for a plastic surgeon who does a lot of ER surgeries. He is non-par with every company except Medicare. A typical ER bill includes a surgery, debridement, physician-administered nerve block, and an ER E/M service.
Because it's ER, and neither the patient nor the doctor can choose each other or verify insurance at time of service, claims are usually processed and paid at a good rate. Recently, however, Horizon has begun to apply CCI edits (bundling) and multiple surgery discounts to reduce the amount they pay significantly.
If that's how they want to process it, I'm okay with it, but then they put $0 as patient responsibility on the EOB, and the patient thinks they have no further obligation to pay when they receive a bill for the balance from us.
Here are my questions:
1. Can I balance bill a patient for the difference between the amount charged and the amount paid by insurance in this situation?
2. Do I need to worry about CCI and multiple surgery discounts if my doctor is non-par?
3. If not, how do I get the patient to understand that when the EOB says that they have no financial responsibility beyond what was paid by insurance?
4. Can you point me to a law or something concrete that I can show the doctor (and have for myself)?
Hope this makes sense. Thanks in advance for your expertise.
Lynn