Otolaryngology Coding Alert

Question: We have a patient who wants us to give her the allowable amounts for a procedure so that she can pay that instead of her deductible because she has a very high deductible. Is this legal?

Texas Subscriber

Answer: If your otolaryngologist has a contract with the insurance company, you have to submit the claim to the payer and collect the amount due from the patient per the explanation of benefits (EOB).

Pitfall: If you do not submit the claim, there is nothing to prevent the patient from submitting the claim and being reimbursed (for example, if the deductible is not as high as she is saying it is) and the practice getting in trouble with the payer for not following their contract.

Additionally, without submitting a claim with all of the charges, you cannot ever be sure of what the "allowable amounts" are. Even if you have the payer's fee schedule, each patient has a different plan, each plan paying different amounts, with different deductibles. Without a claim and resultant EOB, your practice will not know that patient's allowable fees.

Don't forget: If your practice does not participate with the plan, you should not be reducing the amounts to "allowable amounts" since the practice's fee schedule is allowable in any non-participating situation.

Answers to You Be the Coder and Reader Questions reviewed by Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CENTC, CHCC, president of New Jersey-based CRN Healthcare Solutions.