General Category > General Questions

Allowed Amount

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PMRNC:
Are you the biller? If so you might want to have access to contracts and fee-schedules rather than have the facility owner or physicians look it up, they rarely know which end is up. If you are doing the billing, you really should have access to all plan contracts and fee schedules.

kittykat:
They want me to eventually bill for them but I don't know much about it yet but this was a problem they ran into the other day and didn't know what to do. They had a biller who just walked out one day so they are scrambling.

One other question. If they are out of network how would we know the allowed amount? Since they don't have a contract and the ladies I talked to at the insurance company said they don't have that information. Is there somewhere I can find it myself?

PMRNC:
If they are not contracted that means fees are subject to U&C / R&C (Usual or Reasonable & Customary). Carriers don't give out that info. If you call to verify benefits you can ask them if your fee is within U&C but they will not give out the U&C. If your office does high dollar value services it might be beneficial to submit a pre-determination of benefits to carriers your not contracted with.

Michele:

--- Quote from: kittykat on November 02, 2016, 02:51:47 PM ---If they are out of network how would we know the allowed amount?

--- End quote ---

If they are out of network they really don't need to know the allowed amount do they?  They would bill their regular fees.  Payment is most likely going directly to the patient in that case.

PMRNC:

--- Quote ---If they are out of network they really don't need to know the allowed amount do they?  They would bill their regular fees.  Payment is most likely going directly to the patient in that case.

--- End quote ---

The patient might like to know. With my ped's we do a pre-deterrmination of benefits for certain procedures. We provide the carrier with the CPT, anticipated fee and they tell us Yes or no it's within U&C. This of course is for non-contracted providers. This way we can advise the patient that there will be some out of pocket. The carrier won't tell us the U&C amount but they will tell us if our fee is within U&C. We do this for high dollar procedures.

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