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Lowering patient balances after insurance

  1. Post Lowering patient balances after insurance
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    Hi, I am looking for some information on changing the patient balance to a smaller amount after we bill insurance. I have a provider that only wants to charge all office visits after insurance a certain amount. That usually means I have to give the patient more of a discount after their insurance has been billed. I am wondering if this is legal to do.

  2. #2
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    Harrisburg Pennsylvania Chapter
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    If the provider is contracted with the insurance company, the full amount owed after the insurance has paid its portion must be collected.

    Let's assume your provider participates with Acme Insurance, charges $100 for XYZ procedure and Acme Insurance reimburses that at $78. Your provider must collect the full $78. So, if the patient's deductible hasn't been met, the provider must collect $78. If the copay is $30 and the insurance paid $48, the provider must collect the full $30. If the patient's coinsurance amount is 20%, the provider must collect $15.60. The only way that this can be adjusted is if the patient demonstrates financial need according to the provider's policy and procedure. Whatever formula is used to determine financial need must be documented and it must be applied equally no matter who is the patient.

    If your provider is not contracted with the insurance company, then the rules are a bit different. In these cases, it is OK to balance bill the patient for the difference between the "usual and customary" reimbursement rate and the provider's charge. In cases like this, I know of no rules (unless something is specific to your state) that would prevent the provider from legally collecting less.

    Hope this helps!
    Last edited by Skymom; 10-12-2018 at 12:08 PM.

  3. #3
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    Discounting a bill after submitting a claim to insurance can put your practice at risk because it can be considered a violation of the false claims act. The amount that the provider charges and expects as payment in full should be accurately reflected on the claim. If the provider is actually willing to accept a lower amount for that service, but submits a claim showing a different amount, then that is a false claim. It is legal to discount amounts that the insurance company has agreed to in writing under any contracts with that payer, and it is usually legal to offer discounts to self pay patients (since no claim is being filed), but it is a non-compliant practice and most likely not legal to submit a claim for one amount but agree to accept a different amount from the patient as payment in full. This has been addressed by the OIG and there are publications available on their web site that explain this in detail.
    Thomas Field, CPC, CEMC

  4. Default What if Medicare is secondary and the Medicare allowed amount is less than $78?
    Quote Originally Posted by Skymom View Post
    If the provider is contracted with the insurance company, the full amount owed after the insurance has paid its portion must be collected.

    Let's assume your provider participates with Acme Insurance, charges $100 for XYZ procedure and Acme Insurance reimburses that at $78. Your provider must collect the full $78. So, if the patient's deductible hasn't been met, the provider must collect $78. If the copay is $30 and the insurance paid $48, the provider must collect the full $30. If the patient's coinsurance amount is 20%, the provider must collect $15.60. The only way that this can be adjusted is if the patient demonstrates financial need according to the provider's policy and procedure. Whatever formula is used to determine financial need must be documented and it must be applied equally no matter who is the patient.

    If your provider is not contracted with the insurance company, then the rules are a bit different. In these cases, it is OK to balance bill the patient for the difference between the "usual and customary" reimbursement rate and the provider's charge. In cases like this, I know of no rules (unless something is specific to your state) that would prevent the provider from legally collecting less.

    Hope this helps!
    What do you do when the insurance plan contract says you must collect the deductible, coinsurance amounts and the patient also has Medicare as a secondary payer with the allowed amount being less than what the primary paid. Medicare is going to say you can't collect the deductible or coinsurance because you made more than what they allow. Yet, your primary insurance plan contract says you are required to collect the deductible and coinsurance amounts? What do you do, collect or write it off?

  5. #5
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    Quote Originally Posted by Joette View Post
    What do you do when the insurance plan contract says you must collect the deductible, coinsurance amounts and the patient also has Medicare as a secondary payer with the allowed amount being less than what the primary paid. Medicare is going to say you can't collect the deductible or coinsurance because you made more than what they allow. Yet, your primary insurance plan contract says you are required to collect the deductible and coinsurance amounts? What do you do, collect or write it off?
    COB is completely different. If primary pays more than what secondary would consider payment in full, the patient obligation has been met. There is no inducing referrals or kickbacks being offered when you follow the secondary EOB
    CRC (2018), CPC-P-A (2016), COC-A (2016), CPC-A (2015), PAHM (2010)
    Contract/Fee Specialist - Remote

    20 years health insurance experience: Audit, Claims, Customer Service, Payment Policy, Provider Relations, and Reimbursement

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