Wiki ABN/Balance Billing

[y_anderson1]

Is a practice/facility able to balance bill for a service/item that IS covered by a contracted plan but not up to the amt that the practice/facility deems acceptable?

IE.....at a DME facility, a patient wants a knee-walker. the patient has wellmark bcbs and the facility IS contracted with that payer; however the payer's allowed amt is $20 on a total charge of $150. in order to make up for the difference, is it acceptable for the facility to have pt sign an ABN and then collect the difference of what wellmark allows and what the facility bills out?

I've always thought ABNs are for NON-COVERED services, not just to make up difference in allowed amt and billed amt. Please advise and provide resources.

 

[ehanna]

Is a practice/facility able to balance bill for a service/item that IS covered by a contracted plan but not up to the amt that the practice/facility deems acceptable?

IE.....at a DME facility, a patient wants a knee-walker. the patient has wellmark bcbs and the facility IS contracted with that payer; however the payer's allowed amt is $20 on a total charge of $150. in order to make up for the difference, is it acceptable for the facility to have pt sign an ABN and then collect the difference of what wellmark allows and what the facility bills out?

I've always thought ABNs are for NON-COVERED services, not just to make up difference in allowed amt and billed amt. Please advise and provide resources.

No you are not allowed to bill the balance of what you feel is owed if you are a contracted provider. If you look at your contract with Wellmark you will see that when the contract was signed your company was agreeing to ahere to their fee schedules.

If the patient wishes to purchase the walker outright and not have it billed to insurance then that would be acceptable but if you are "par" with an insurance company typically you have agreed to live with their fee schedules. I hope this helps

 

[Kentuckygirl1984]

This is totally not where this is supposed to be but where do I go to apply a new post on this discussion? I did it once before I cannot figure it out can somebody help me? thanks

 

[mhstrauss]

This is totally not where this is supposed to be but where do I go to apply a new post on this discussion? I did it once before I cannot figure it out can somebody help me? thanks

Above all these replies, there's a link "AAPC Medical Coding and Billing Forums". Click there to get back to the Forum main page, then select the topic category you would like to post under. The most recent threads will be displayed; "New Thread" is above the list of threads.

 

[mhstrauss]

Is a practice/facility able to balance bill for a service/item that IS covered by a contracted plan but not up to the amt that the practice/facility deems acceptable?

IE.....at a DME facility, a patient wants a knee-walker. the patient has wellmark bcbs and the facility IS contracted with that payer; however the payer's allowed amt is $20 on a total charge of $150. in order to make up for the difference, is it acceptable for the facility to have pt sign an ABN and then collect the difference of what wellmark allows and what the facility bills out?

I've always thought ABNs are for NON-COVERED services, not just to make up difference in allowed amt and billed amt. Please advise and provide resources.

I agree with ehanna; your "resource" is the contract signed with the payer stating that you will accept their paymet, less patient responsibility. Some things to consider though, if your facility plans to continue to provie DME...compare the payer's allowed amount to your cost of the product, including taxes and shipping. Your charge amount is pretty much irrelevant when billing to contracted payers. If the payer's fee is less, use the invoice to renegotiate a higher fee that will cover your cost. If the payer will not negotiate, you should probably stop providing DME to patients under that plan. You'll only lose money if you continue.

 

[y_anderson1]

I agree with ehanna; your "resource" is the contract signed with the payer stating that you will accept their paymet, less patient responsibility. Some things to consider though, if your facility plans to continue to provie DME...compare the payer's allowed amount to your cost of the product, including taxes and shipping. Your charge amount is pretty much irrelevant when billing to contracted payers. If the payer's fee is less, use the invoice to renegotiate a higher fee that will cover your cost. If the payer will not negotiate, you should probably stop providing DME to patients under that plan. You'll only lose money if you continue.

This particular payer is the only one who pays at such a low contracted rate. I am glad you and ehanna agree. I was completely caught off guard by this when the situation arose. I just wanted confirmation that I was not misinformed abt what the ABN is for. I too agree that we have to accept the contracted rate.