Balance Billing Patient for -51 Modifier Reduction


Champaign, IL
Best answers
Is anyone out there doing this? For commercial payers, of course. We have an area provider that routinely balance bills patients for the the 50% reduced by payers for correctly taken mutiple surgery reductions. We have patients in common and they are very upset. I have always be taught at seminars, etc that this is not an ethical practice. I just wondered if anyone out there has justification for this very patient-unfriendly billing practice.

If that practice is contracted with that patients insurance carrier, then this would be fraudulent. I'm sure that the patient's EOB states (or should) what the patient responsibility is.
I agree with Mary.
If these provider is "par" with the payor, patient resp. per EOB needs to be adhered to.

Unfortunately, if the provider does not "par" with the particular payor, then that provider can bill the patient for any balance between total charges and what the insurance pays (happens to me all the time with my dentist office)
On one hand, the provider has no contractual obligation to take the multiple procedure reduction, however, this discount is accepted and taken on all participating payer claims......doesn't seem right.

I preach consistency to my billing staff. If an accepted society OR CPT defined appropriate multiple procedure discount is applied we take it - par or nonpar. If an inappropriate discount is taken (and we've all seen this - payers fishing for reasons to reduce their payment) then we immediately appeal- again par or nonpar. If we are non par (inappropriate reduction) - I have no problem billing the patient because I have appealed to the payer noting their error/misinterpretation of billing/payment guidelines & sent a copy to the patient. I have templates that we use to appeal so we can just drop in the appropriate phrases/information. It takes 2 minutes and our patient's appreciate our straight forwardness. I also feel, since we are adhering to our society OR CPT Billing Guidelines, that our billing practices are less likely to be effectively challenged.

Julie, CPC
Balance Billing

Again, I speak from the insurance company aspect. If the provider is PAR, then GENERALLY, there is a "contractual obligation" to take the reduction; in most instances, in order to BE participating with an insurance company - a contract is signed stating your agreement to their payment methodology. If a provider IS participating and FAILS to adhere to that agreement - the insurance company has a right to terminate the agreement. The key to this whole discussion would be the EOB. Follow whatever the EOB states - if it states a provider must write-off, then that is what needs to be done. How an office handles the same scenario where they are NON-par with a payor - is a policy issue. However, if the EOB indicates the patient is responsible, then, legally they are responsible. Just my humble thoughts. :p
I agree with ckkohler - if participating then provider has to write off.
But, as well all know, often times NON PAR EOBs reflect the incorrect patient responsibility and this goes beyond multiple procedure discounts. A NON PAR EOB might have a column of U/C that is not a provider write off AND is not reflected in the patient responsibility - Aetna is notorius for this. Because of this, it's important that the person posting the payment has the knowledge to identify an erroneous disallowed amount which may be indicated on the EOB as a discount or disallowance (and may or may not be reflected in the remaining patient balance).

I continuously conduct post-pay audits within our practice to identify underpayments and overpayments.

Julie, CPC
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