Results 1 to 6 of 6

Balance Billing Patient for -51 Modifier Reduction

  1. Default Balance Billing Patient for -51 Modifier Reduction
    Medical Coding Books
    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.

    Thanks!
    Amy

  2. #2
    Location
    ENGLEWOOD/DENVER
    Posts
    2,338
    Default
    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.

  3. #3
    Location
    Albany, New York
    Posts
    456
    Smile
    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)
    Karen Maloney, CPC
    Data Quality Specialist

  4. #4
    Default
    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

  5. #5
    Location
    Omaha, Nebraska
    Posts
    144
    Default 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.

  6. #6
    Default
    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
    Last edited by jdrueppel; 11-26-2008 at 05:17 PM.

Similar Threads

  1. Balance billing patient for out-of-network plan
    By JesseL in forum Billing/Reimbursement
    Replies: 1
    Last Post: 07-13-2014, 08:08 PM
  2. What happens to balance if patient past away?
    By SCCL5558 in forum Medical Coding General Discussion
    Replies: 1
    Last Post: 09-24-2012, 11:48 AM
  3. Balance Billing Patient
    By lpyrtle in forum Compliance General Discussion
    Replies: 1
    Last Post: 03-30-2011, 12:39 PM
  4. Patient Balance need help?
    By ivonneatanacio in forum Billing/Reimbursement
    Replies: 2
    Last Post: 11-15-2010, 10:01 AM
  5. Patient Balance need help?
    By ivonneatanacio in forum Orthopaedics
    Replies: 0
    Last Post: 11-05-2010, 08:43 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?

Login

Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.