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Urology Coding Alert

Reader Questions:

Submit All Claims to a Contracted Payer

Published on Sun Jun 13, 2010

Question: We have a patient who wants us to directly bill her allowable charges for a procedure so that she can pay our office this amount instead of paying her deductible since she has a very high deductible. Is this legal? Texas SubscriberAnswer: If your urologist has a contract with the insurance company, you must submit the claim to the payer and then collect from the patient only the amount indicated by the explanation of benefits (EOB).Pitfall: If you do not submit the claim, there is nothing to prevent the patient from submitting the claim and being reimbursed, and the practice then being accused of noncompliance with the payer-physician contract.Additionally, without submitting a claim with all of the charges, you cannot ever be sure of the "allowable amounts." Even with a payer's fee schedule available to the physician, each patient may have a different plan, with each plan paying different [...]
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