PPO INSURANCE BILLING

[Elizabeth]

Good morning,
I have some concerns regarding the deductible and coinsurance for PPO patients.

A specialist saw a patient for visits in his office in October and November 2020, on the dates of service the patient had not met her full deductible and out-of-pocket expenses: I have some questions about her billing.
1. If the patient has not met her deductible and out-of-pocket expenses by December 31, 2020, will the entire visit be deducted from the doctor's fee?
2. If the patient starts 2021 with a deductible and out-of-pocket expenses at zero again, what happens to the 2020 visits that have not been billed?
3. 3. If the maximum billing time is one year, I can wait to bill until 2021 for the deductible and out-of-pocket expenses to be met or the allowed amount will be deducted from the doctor's fee because it was not met in December 2020.

I really appreciate your help, I am new to PPO billing, so I would appreciate your feedback. Thanks

[Michele]

Good morning,
I have some concerns regarding the deductible and coinsurance for PPO patients.

A specialist saw a patient for visits in his office in October and November 2020, on the dates of service the patient had not met her full deductible and out-of-pocket expenses: I have some questions about her billing.
1. If the patient has not met her deductible and out-of-pocket expenses by December 31, 2020, will the entire visit be deducted from the doctor's fee?

Your wording is a little off, so I'm going to rephrase it in the answer:

If the patient hasn't met her deductible for 2020, any visits billed to her insurance will be applied to her deductible until it is met.  So the allowed amount for the service will be patient responsibility and the patient should be billed for that amount.

2. If the patient starts 2021 with a deductible and out-of-pocket expenses at zero again, what happens to the 2020 visits that have not been billed?

All visits for 2020 should be billed, and will be processed and applied to the deductible until it is met.  It doesn't matter if they are billed in 2020 or 2021, it goes by the date of service.  The 2021 visits will also be processed and applied to the deductible for 2021 until that is met.

3. 3. If the maximum billing time is one year, I can wait to bill until 2021 for the deductible and out-of-pocket expenses to be met or the allowed amount will be deducted from the doctor's fee because it was not met in December 2020.

Each year is totally separate.  If 2020 is not met it doesn't affect 2021 charges.  Only the 2021 deductible affects the 2021 charges.

You can wait to bill your claims, if the filing limit is 1 year, and hope that other providers will submit claims that are applied to the deductible.

I hope that helps!

[Elizabeth]

I really appreciate your answers, they were very helpful.