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Thread: Coding Question

  1. #1

    Default Coding Question

    AAPC: Back to School
    Is it legal to bill a patient a different amount just beacuse they have insurance versus a person that doesn't have insurance. Like if a person that is considered self-pay or has an insurance that won't pay for a visit allowed to be charged a different/higher amount than a person that has the insurance that will 100% cover the visit.

    What are the repercussions that can happen to the coder that is posting the charges that way?

  2. #2
    Join Date
    Apr 2007
    Milwaukee WI

    Default The fee is the same / The adjustment varies

    The fees are the same for everyone. HOWEVER ... the adjustments vary based on contracts and written policies in place.

    For example let's say all following patients have the same service/procedure for which the fee is $100

    Patient A has commercial insurance which pays at 80% of billed fee. (our adjustment is $20)

    Patient B has commercial HMO (we are in plan) which pays at 80% of ALLOWABLE .. in this case $75 allowable (our adjustment is $25)

    Patient C has Medicaid which pays $35 for this procedure (our adjustment is $65)

    Patient D is self pay without insurance, which per our written policy we automatically discount by 10% (adjust is $10)

    Patiend E is self pay without insurance and had filed financial hardship paperwork; qualifies for 100% charity care (adjustment is $100)

    You get the idea...

    F Tessa Bartels, CPC, CEMC

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