Wiki Billing Patients Less Than Allowable Amount?

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ChristineW0729

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Are we allowed to bill a patient less than what an insurance company allows? We have a few patients in which a Medicare Advantage insurance has allowed more than they should, and dropped the full allowable amount to the patient, which happens to be their full copayment for an ASC. We have tried to call to get these to reprocess and allow the correct amount; we have tried appealing these to get the insurance to reprocess and allow the correct amount, but they continue to say they have processed correctly.

Usually, when procedures have an allowable that is less than a patient's copay, they only drop the allowable amount to copay. However, in this instance, the insurance company has actually done debit adjustments to increase the allowable to be the patient's full copay for an ASC... Could we drop the balance of only what we expect and contractually would allow for this procedure? (In this instance, we'd be dropping less than what the insurance left to patient responsibility, but it would be the correct amount that they should have allowed for this procedure) I cannot find any specific language in our contract that states anything about this, only that we cannot collect more than what the insurance allows.
 
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You should be billing your patients for any insurance applied deductible, co-insurance or copay. In this situation, you are stating the insurance company has processed the claims incorrectly. I would await a corrected EOB.
Is it possible that you are mistaken or that the claim was billed incorrectly since they are not reprocessing for what you believe to be correct?
 
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I agree, the patient should be billed what the insurance company says they owe, especially if it's a Medicare Advantage patient. It's up to the payer to determine what the patient share is, not the provider.

Without looking at the individual claims, it's hard to speculate about what's happening here. But if you're seeing a debit adjustment in some cases that raises the allowed amount above the billed charge, this is not an error. Medicare payments to facilities under OPPS will sometimes price claims this way and this is correct because they're paying based on the average cost for a class of types of service. Unless your contract has 'lesser of' language (e.g. stating that the allowable will be the lesser of the fee schedule or the billed charges), then your allowable will not be capped at billed charge.

I agree with Christine here, you should follow what the EOB says. It's good that you're advocating for your patients, but I think you're doing the insurance company's work for them. It's their responsibility to put the correct patient share on the EOB, and if the patient disagrees with what the payer has determined, that's between them and their plan to work out.
 
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The Medicare advantage is allowing more than the Medicare fee schedule, so yes, I do believe we are correct in thinking that they have processed incorrectly. To put it in example numbers, say Medicare only allow $275 for a procedure. The Medicare advantage is allowing $300, even though they should be processing at 100% of Medicare's rates. I will have to do further appeals with the insurance company to get them to reprocess.
 
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We have contracts with Medicare Managed Care plans that pay us at a higher rate than the Medicare rates, so I don't this that it is unusual that you received more. You should see if you can get a copy of your Fee Schedule from the carrier to verify what your contracted rates are, as they could be more than MCR rates.
 
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That's a good idea. It's just that they are allowing different amounts for the exact same procedure. We are billing 62321 and sometimes they allow the correct amount, and then on the same remittance they allow more for a different patient. That to me seems like an inconsistency especially when the same CPT code was billed.
 
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With reference to Medicare Advantage plans, I don't think any of our contracts are at the Medicare fee schedule; they are all higher. For MA plans that we are out of network, then the allowable is typically the Medicare fee schedule.
Depending on your contract and the particular carrier, there are definitely carriers that have different allowable amounts dependent on the patient's specific type of plan. For example, Oxford Metro plan may have a different allowable than Oxford Freedom plan. HIP VIP Medicare, HIP Medicaid and HIP commercial all have different fee schedules.
 
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