Wiki Balance billing patient for out-of-network plan

[JesseL]

We have a patient who has medicare as primary and horizon bcbs. Medicare paid 80%, horizon denied the 20%. According to Horizon, we can no longer bill the patient for the 20% medicare co-insurance just because we sent the bill to them.

Is this true? I asked someone else and they said if I checked off "accept assignment, line 27" on the claim form, that means I accept Horizon's denial and cant bill the patient. Is this true also?

I thought because we're out-of-network we're not bound by anything and have the right to balance bill the patient for whatever's not covered.

Help appreciated.

 

[bonn715]

that seems to be based on both the insurance and the provider's interpretation of the rule. When i Google assignment of benefits and OON and the first one that came up was Horizon of NJ
http://www.horizon-bcbsnj.com/misc/Assignment_of_benefits_to_out_of_network.html, and if I was disputing this one w/them I would mention to them that in this states only that they can pay the provider directly for out of network claims, not that we have to accept the allowed amt. it also states that they can also pay the member, with most providers if the member is paid there is no discount, no expectation to take an adjustment. and the whole reason to contract with the provider is to get that discounted rate in the first place. With government payors, box 27 means that the insurance can send the payment directly to the provider -and the ins listed in box 33's allowed amt will be honored. With commercial payors like Horizon, box 27 only means the payment can be sent to the provider.
If they still dispute, ask them to provide documentation to support the adjustment. I checked 5 sites an they all said it only means the insurance can pay the provider instead of the patient, and in some cases it is a law because the ins sends the OON check to the pt then the provider never sees any monies for services.