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Pediatric Coding Alert

Reader Question:

Know How to Handle Deductible Balance

Published on Tue Jul 31, 2012

Question: Our patient has two insurers--Payer A is the primary and Payer B is the secondary. We performed a procedure and Payer A paid $120. The claim then went to Payer B for the balance of $50.00, but that whole amount went to the patient's deductible, so that $50.00 is still owed to us for this claim. Is the patient responsible for paying us this $50.00?

California Subscriber

Answer: It's hard to say for sure whether the patient can be billed without additional details, but in general, a few variables can come into play in this type of scenario.

Although we don't know the specifics of your case, we'll assume three truths: (1) The doctor has no contract with Payer A or Payer B, (2) The plans are not Medicaid plans, and (3) These are not HMO Plans under a state no balance billing HMO law.

In addition, we aren't sure the original charge amount that you billed at the outset. However, in most cases, the patient does owe you the amount that was applied to the deductible. But depending on the variables (contract, Medicaid, state HMO no balance billing law), then the patient may also owe the difference between charges and payment.

For example: Suppose you charged $200 for the service. Payer A allows $50 and applies the whole thing to the deductible. The patient still owes the difference between the charge and allowed amount because the doctor is non-par. Even though $50 was applied to deductible, the patient owes the full $200. Payer B allows no more than what the primary paid, so they deny the claim. The patient still owes $200.

If the doctor is non-par, the patient owes what his insurance plans didn't pay up to the amount of the doctor's charges, whether it's an "applied to deductible" situation or not.

This becomes more complicated if the doctor is contracted because you would need to see the contract language. If the plans are Medicaid payers or if there is a no-balance billing law, it is even more complicated.

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