Wiki balance billing

[ASH527]

I have a question, which I pretty much know the answer but would like clarification - Have a patient that had a CT scan performed and the facility billed $6500 for the service - the insurance - BS allowed $7600 and paid $5200 - with this info I know we can bill the patient the difference of $1300 ($6500 - 5200 = $1300) but we cannot bill the patient more just because the insurance allows more - am I correct as this would be fraudulent billing as our charge for the service is $6500 not $7600 and we wouldn't be billing the higher charge across the board to all other carriers or patients. The patient has disputed this and I agree - but our billing manager insists the patient owes more than the $1300

Any comments/suggestions would be appreciated

 

[mhstrauss]

I have a question, which I pretty much know the answer but would like clarification - Have a patient that had a CT scan performed and the facility billed $6500 for the service - the insurance - BS allowed $7600 and paid $5200 - with this info I know we can bill the patient the difference of $1300 ($6500 - 5200 = $1300) but we cannot bill the patient more just because the insurance allows more - am I correct as this would be fraudulent billing as our charge for the service is $6500 not $7600 and we wouldn't be billing the higher charge across the board to all other carriers or patients. The patient has disputed this and I agree - but our billing manager insists the patient owes more than the $1300

Any comments/suggestions would be appreciated

I agree that you cannot bill the patient higher than the amount you charged to the insurance. The "allowed amount" is actually the lesser of the Charged Amount vs. the Contractual Amount. But I would definitely recommend reviewing your standard fee schedule; if there are payers whose allowed amount is higher than your charge, then you aren't maximizing reimbursement. Your fee schedule should always be a little higher than the highest contract amount across the board.

Hope that helps!