Billing > Billing
out-of-network billing
PMRNC:
Yes, providers have to do their part in upholding the contractual relationship between the policy holder and the insured/dependents. ie; any cost sharing. So for example if the OON plan pays 80% of the first $2000 in Out of pocket expenses, the patient is responsible for their 20% (cost sharing) So if a provider discounts any service, he has to bill that with the discount to the insurance company. They are entitled to any discount just as the patient would be.
Jdmontee:
Am I understanding from these posts that if a provider is out of network with an insurance, the provider can choose to accept the out of network payment as payment in full and not balance bill the patient? Or can negotiate a reduced payment from the patient for anything the insurance does not cover???
Thanks!
Joanne
PMRNC:
No, providers cannot routinely waive out of pocket nor enter into private contracts (verbal or otherwise) that would violate the patient's insurance policy of "cost sharing". So if a doctor is out of network with a carrier and bills $100 and they pay $80. The patient is legally responsible for the $20 and the provider is legally obligated to attempt and collect it.
Jdmontee:
Ok, that's what I thought but the posts seem to go back and forth regarding what a doctor is obligated to in an out of network scenerio. Bottom line...out of network...provider is obligated to balance bill patient for anything the EOB shows as patient responsibility correct? Just want to be sure as I have one provider who is out of network with most insurances. I onlyprovide claims billing for this provider and provider bills patient themselves for any balances. I want to be able to provide accurate info to him to be sure HE is doing what is correct and legal on his end.
Thanks much!
Joanne
PMRNC:
No, REGARDLESS of in/out of network: Physicians can not routinely waive out-of pocket expenses. (PERIOD) So if you have a provider in network and a patient has $10 copay, the physician must make an attempt to collect that copay (OOP)
And likewise with coinsurance (OON)
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