Pediatric 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?

Answer: If your pediatrician 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 your practice could be questioned by 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.