Balance Billing

lveburg

New
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5
Location
Stromsburg, NE
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When is it legal to balance bill? We are not receiving our cost for J7307 (contraceptive implant system) from commercial insurance companies. Is it legal to bill the patient for the difference?
 

csperoni

Expert
Messages
319
Location
Selden
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If you are participating with the insurance, I am 100% certain that your provider contract will prohibit balance billing. For participating providers, balance billing is not a legal issue, but a contractual one. For non-participating providers (in NY state at least), they MAY balance bill provided the patient was aware provider is out of network.
It is not all that uncommon for there to be certain procedures where your cost is less than reimbursement. We don't specifically provide that service, but sometimes others like IUD or HPV vaccines can encounter the same issues. Suggestions to reduce those instances:
1) Know in advance - especially for low payors - what the fee schedule is. Sometimes you can obtain the device or drug through the patient's pharmacy benefit.
2) Try to negotiate a higher reimbursement before providing the service. If you are a private practice not affiliated with a larger health system or IPA, good luck with that.
3) Try to negotiate your expense in purchasing the drug/device. Again, if you are a private practice not affiliated with a larger health system or IPA, good luck.
Notice both 2 and 3 can be remedied by joining an IPA if you are a small private practice. IPAs are large groups of physicians that have negotiating power. Joining an IPA will often get you a better fee schedule and access to discounted products. If the IPA negotiates with a pharmaceutical company, that company knows all the physicians in that group are buying their device/drug A vs competitor device/drug B.
If you can't do those things and you are participating, then you may decide the best option is to not provide that specific service.
 
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