Payments > Patient Billing

Benefit misquote = tough situation =advice needed

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Hi there,
Iím sure this has happened to some of you at some point and you had to make judgement call.

Hereís our pickle:

Insurance company was contacted by our office by phone to verify pt. eligibility and benefits. As is usually the case, we give the procedure code and ask if any precert is required and if there is a deductible or coinsurance so we can let the patient know and estimate what their financial responsibility would be.

The info we received was that it would just be a $60 co-pay per visit.

The claims came back showing all charges went to the patientís deductible. We call the insurer and are told the plan has a $2500 deductible. At this point the patient now owes us a couple thousand dollars instead of the co-pays we told them.

At this point what do you do? The insurance company took our reference number for the original call to see why the misquote was given. I doubt they will actually do anything or look into it at all.  Can we appeal this as the providerís office? If so, in your experience, is there any chance the insurer will reprocess the claims at the originally quoted level?

Can the patient appeal this to the insurer? In your experience, do you think doing either of these things will make a difference?

On a side note, what would your office do in this situation? Hold the patient responsible for the entire bill, perhaps with a payment plan?

Discount the charges and offer a payment plan?


This is unfortunately something that does seem to happen from time to time.  It is unfortunate that it is such a high balance.  The problem is that almost all of the insurance carriers have a recording or some sort of disclaimer stating that information obtained "is not a guarantee of benefits.  Benefits will be determined once a claim is received."  So therefore you have little recourse.  However, I would still recommend that you try.  Since you do have a reference number for your call at least have them look into it (which you have done).  In some cases we have seen insurance carriers honor benefits that were misquoted, but that is unusual.   I also think it would help if the patient contacted them as well.  They should know that the patient is upset about this misquote and that it is costing the patient a lot more out of pocket than they thought (although it may not help because ultimately it is the patient's responsibility to know their plan benefits).

If they decided that they will not honor the misquoted benefits, then you will have to decide how you want to handle it with the patient.  Whether or not you want to give a discount is really a personal decision.  Although I know as a patient I would appreciate that gesture.  Also, the payment plan is almost a must since it is such a high amount.

:(  Wish I had better advice.

What Michele said.

1.  All of our clients have their patients sign a statement that the patient is responsible for payments due for services rendered.  Whether or not the patient has insurance is the patient's business, not the provider's business.

2.  At any given point in time, neither the doctor's office nor the insurance company can know for certain what medical attention the patient has had recently.  This introduces the possibility that other charges will post to the patient's insurance before your provider's charges do.  Because of this possibility, neither you nor the insurance company can ever state for certain what the remaining deductible is for a given patient.

Point Number 2 is why Point Number 1 exists.  We always inform those who ask that we won't know what the patient actually owes until their insurance has processed our claim for their date of service.  Because, as you've discovered, that is actually the truth.

In our case, we would send the patient a statement, indicating what insurance monies went to their deductible and what the remaining balance is that they owe the provider.  There are always special circumstances where the provider will allow some sort of discount.  But the prevailing approach is that the patient received the services, so the patient is responsible for payment of those charge amounts allowed by the patient's insurance carrier and not paid by them to the provider.

I agree completely with both Michele and Richard's replies, and have found myself in your exact situation a few times over the years. Because we do have the patients sign both a financial policy and the initial paperwork when they are new and part of what that paperwork says is that the patient is ultimately responsible for all charges incurred, we can then rightfully bill the patient when we are misquoted benefits. That said, when this has happened, we have offered both a discount and payment plan, depending on the situation. While deductibles and co-pays are not supposed to be routinely written off/discounted, this is not routine, it is a special circumstance.

I would really encourage the patient to get involved in trying to appeal what has happened here. Recently, I had a situation in my office where I called and got benefits on some DME for a patient. I gave both the HCPCS code and the diagnosis code, and was told by the rep that insurance would cover 70%, and the patient was liable for 30%. The DME was provided, and the claim sent in, and then denied as a non-covered service. When I called them about it, I was told by a different rep that the service was covered, but only for a very specific set of diagnoses, that the patient didn't have. I told the rep that the first rep I spoke to a month previous had NEVER mentioned this, and that he had said the diagnosis I provided was covered. This rep said "oh well, so sorry about that, but there is nothing you can do". Oh, really?

What I did was called the patient, explain what had happened, and the patient came into the office, and we sat together and called the insurance company back, and the patient went to town on them, while I listened, then I had my say with them, and told them to pull the record of my first call, and they would see that we were misquoted benefits. Let me tell you...the insurance company took notice that we were seriously going to be pursuing this, and within two weeks, they not only paid for the service, they paid it at 100%, not 70%. Their employee screwed up, and there was no reason for our office or our patient to have to eat the cost of that mistake. So get the patient involved, you may get a results that way.

Thank you all for your input.

I can tell you with certainty the patient is going to tell me they would have ever come in for the services if they knew they would owe this amount of money.

Iím going to see what we can do and try to get the patient involved. If there is no resolution with the insurer, we're going to end up deeply discounting and trying to set up a payment plan.

They sign all the above described forms when they come in and we certainly would be within our rights to hold them responsible for the full amount, however we also want to protect the reputation of the practice and work out a reasonable solution. Nothing can be worse for business than an angry patient who feels they were somehow cheated and wants to share those views (although erroneous) online.


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