# Lesser of billed provision



## jans2765 (Sep 27, 2017)

We billed a claim with several CPTs, and the allowable for the primary code was higher than the entire amount of the claim. When this happens, we expect the claim to allow at 100% of 'billed' charges. However, the payor paid less than the billed charges. I inquired about this, and their response was it hit lesser of billed provision.

Does anyone know what this means in simple terms? Their response was a little over my head.
Thank you!


----------



## CodingKing (Sep 27, 2017)

Are you talking about a COB situation? Maybe I'm not following?

Lesser of typically means, If allowed amount is lesser than what is billed, provider writes off the difference. 

For COB it means secondary carrier allows no more than it would have had they been primary. For instance Primary allowed $100 and secondary allows $50. Its considered paid in full.


----------



## jans2765 (Sep 28, 2017)

CodingKing said:


> Are you talking about a COB situation? Maybe I'm not following?
> 
> Lesser of typically means, If allowed amount is lesser than what is billed, provider writes off the difference.
> 
> For COB it means secondary carrier allows no more than it would have had they been primary. For instance Primary allowed $100 and secondary allows $50. Its considered paid in full.



Hi CodingKing,

No, it doesn't involve COB, it is just one payor.

I'll give an example:


A. Billed $1,000                 Allowable $2350
B. Billed $450                    Allowable $100
C. Billed $350                    Allowable $75
D. Billed $200                    Allowable $0
Total = $2000                    Total $2525

So, since the allowable for code A is higher than the total of the claim, we are expecting them to allow 100% of claim amount, or $2000. But, they allowed less than $2000 & said it's lesser of billing provision. I believe they can do that, but a few of us are trying to understand the logic. Thanks!


----------



## CodingKing (Sep 28, 2017)

A) $1000 should be allowed since your billed amount is lesser then allowed
B) $100 should be allowed since allowed amount is less than billed
C) $75 should be allowed since allowed is less than billed,
D) $0 should be allowed since the allowed is less than billed.

Total allowable should be $1175.00

The allowed amount over the $1000 on line one does not transfer to the other line items.


----------



## jans2765 (Sep 28, 2017)

CodingKing said:


> A) $1000 should be allowed since your billed amount is lesser then allowed
> B) $100 should be allowed since allowed amount is less than billed
> C) $75 should be allowed since allowed is less than billed,
> D) $0 should be allowed since the allowed is less than billed.
> ...



Hello. Yes, I see that I didn't do my allowable correctly (oops!) but I do agree with you that $1175 is the correct allowed amount. However, insurance allowed less than $1175 and their reason was "lesser of billed provision" and that's the part I don't understand. Because I understood lesser of billed provision to be like you explained it, above where they would allow the entire $1175, not less than that.


----------



## CodingKing (Sep 28, 2017)

In that case, I have no idea.


----------



## coop22 (Sep 29, 2017)

This actually happened to me on a personal medical claim. For three hours all I ever got was this was processed correctly. No reason why.


----------



## jans2765 (Sep 29, 2017)

CodingKing said:


> In that case, I have no idea.



Thanks!! At least we see it the same way. The contract rep was not much help. I may have to try an appeal or see if corporate can decipher anything in the contract that allows the lower reimbursed amount.


----------



## jans2765 (Sep 29, 2017)

coop22 said:


> This actually happened to me on a personal medical claim. For three hours all I ever got was this was processed correctly. No reason why.



That is frustrating. We might even be dealing with the same insurance company.


----------



## OncologyOKC (Oct 3, 2017)

Look at JUST the $1000 line.   How much have they allowed on that line only?


----------

