Wiki Balance Billing

Cwaples

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When a medical office bills a patient's insurance company for multiple services rendered to the patient and the insurance company only pays a portion or denies some of the fees, does the medical office then have the ability to balance bill by charging the full balance (even up to the usual and customary) for all charges to the patient?

For example, Joe has 2 usual services billed to insurance. Service A is billed at $250 and Service B is billed at $100. Insurance pays the medical office $150 for Service A and $0 for Service B due to a contractual agreement. Can the medical office now bill Joe for the difference of $100 for Service A plus the $100 for Service B, making a total balance of $200 billed to Joe.

In addition, does the State (AZ) matter? and whether it is HMO or PPO?


Thank you to all those who respond!
 
Not if you are contracted

Based on your question it sounds like you are contracted with the carrier. If your provider is contracted with the insurance company, then you are prohibited from balance billing. If the 2 procedures are not CCI edits, you can bill with the appropriate modifiers and appeal to the insurance company.
If your provider is NOT contracted, you may basically bill the patient however you wish.

The state and HMO/PPO might come into play if you are NOT contracted in terms of whether the patient was notified prior and given a cost estimate. In NY for example, there is a no surprise bill law that requires a patient to sign a notice and be given a fee schedule upon request if they were referred by a participating provider.

But since your question stated the reduction was contractual, then you may not bill the patient other than insurance applied deductibles/co-insurance/copay.
 
Balance billing

I agree with the other reply. If you are contracted with the insurance company, it will state in the contract that you cannot balance bill the patient. I also agree if it's a NCCI edit then try to get around that with an appropriate modifier or an appeal. There are other ways to get around the situation. I worked for a physical therapy center that would not get reimbursement for treatment and an evaluation on the same day. One could always do the evaluation on one day and then treatment on another day. You could always tell the patient that the insurance company does not cover both on the same day. I have also worked with a provider that was out of network with a lot of insurance companies and they would take the allowed amount as payment and not balance bill the patient for the entire bill amount. They liked keeping the patient happy and coming back. As boring as it is, one must be familiar with the contracts signed by the provider. I hope this helps.
 
You could always tell the patient that the insurance company does not cover both on the same

Actually NCCI added a comment prohibiting inconveniencing the patient to get around NCCI edits.

MUE and NCCI PTP edits are based on services provided by the same physician to the same beneficiary on the same date of service. Physicians should not inconvenience beneficiaries nor increase risks to beneficiaries by performing services on different dates of service to avoid MUE or NCCI PTP edits.
 
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