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Out of Network Confusion

  1. #1
    Question Out of Network Confusion
    Medical Coding Books
    If were are not a participating provider with a particular plan, and we file the claim for the patient, are we obligated to follow CCI edits? I got an EOB from a non par carrier and they are telling me to write off some charges due to edits. Not sure if I am required to make these adjustments or not or is the patient is liable??

  2. Default CCI Edits
    I don't know what the correct answer to your question truly may be, but coding according to CCI edits will prevent possible future recoupment and help to avoid the possibility of fraud allegations. I am looking forward to the answers you will receive, I need more education on this subject also.

  3. Wink
    It is my understanding that if you are not a participating provider you do not need to take the adjustments. I would also like to see what others think....but I do not think you have to take them

  4. #4
    Location
    Wichita, KS
    Posts
    90
    Default
    If there is not a contract with the plan, there is no contractual obligation to honor a discount/write-off. I would think that you could bill the patient for that; however, you may want to consider taking the write-off, or a portion of it, as a courtesy to your patient. Especially if want the patient to return to your office for future services. Just my two cents.
    Jodi Smith, LMSW, CPC

  5. #5
    Thumbs up
    Quote Originally Posted by jodismith View Post
    If there is not a contract with the plan, there is no contractual obligation to honor a discount/write-off. I would think that you could bill the patient for that; however, you may want to consider taking the write-off, or a portion of it, as a courtesy to your patient. Especially if want the patient to return to your office for future services. Just my two cents.
    Thanks for confirming my initial thought. I work for some really great guys, so ethically I don't think he will charge and follow the edits as we would for contracted carriers. I just wanted a second opinion on whether we could bill the patient. Thanks!!

  6. Default
    If the patient is out of network you do not have to make any adjustments for them. They should be aware that if they go out of network that the insurance will only pay about 70% and also keep in mind that they will have a seprate deductable and out of pocket expense for going out of net work.

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