Billing question

[DavidZ]

Short pay by a payor on an out of network claim.
What do you do in a case where you bill $3200 and get back $275?

[Pay_My_Claims]

can't answer that, not enough information.
1. you are OON, you can always bill the patient the balance.
2. what did the eob state? was it a denial or was  the 275 the allowable for the cpt code submitted???
?

[PMRNC]

I think they mean cut in fee due to U&C/R&C?
If so you can appeal it if you have supporting documentation. Depends on what it was, not enough info like Charlene said to make any kind of guess.

[DavidZ]

Thanks guys,
Linda is on the same path, we sent in appeals, with no reply at this time.
Will see what happens.

[PMRNC]

When appealing U&C you have to appeal at each level with supporting documentation.. in otherwords you have to show documentation as to WHY you feel that procedure warranted a higher payout, Op report, office notes.. you do it in levels. The first appeal you do just a letter asking them to re-consider.. SOMETIMES you get lucky and they pay a little more.. if it's still not good payout you file a 2nd appeal (labeling the claim a 2nd appeal) and you attach Op report.. etc.
Sometimes the carrier will pend the appeal and request whatever they think they need. The idea is that each submission should contain ONE more piece of supporting documentation.

[Steve Verno CMBS, CEMCS]

Is this an HMO under State law jurisdiction with no patient balance billing law.

Example:  Florida Statute 641.3154 prohibits balance billing patient.  You can appeal but if they do nothing, your doctor might be able to go to court but may lose because HMO may say what they paid is all they have to pay.

What does the patient benefit manual state the insurance has to pay?
Example:  benefit manual may say the benefit is to be paid at 100% of out of pocket expenses.  It could also say they pay 60% of their UCR and patient pays balance.

Is this an ERISA plan?
Example:  Per 29 CFR 2560-503-1, the benefit payment appeal must be done by the patient within 180 days of the date of the adverse benefit determination. The appeal is per the insurance company appeals process outlined in the patient summary plan description.

[DavidZ]

Got it
thanks