Wiki Balance billing

[Marjoriecoop]

Other web searches suggest that balance billing is legal for an out-of-network provider in an office setting. Wondering if anyone can confirm or deny. Ya know, I trust Dr Google only so much. The patient knew the provider was out-of-network, though in this case both pt and provider were hoping the payor would credential the provider sooner rather than later so a number of visits went unpaid ($0 for out-of-network for this payor). All knowledge welcome.
Marjorie in Massachusetts

 

[matt2374]

Balance Billing

Yes with out of network provider you can hold the patient responsible to the amount of your charge the insurance company when you bill out the claim. Even if the EOB comes back from the insurance company with an allowed amount less than the charged amount you can still bill the difference to the patient. In this case the doctor does not have a contract with the insurance company and can charge any difference between your billed amount and the amount of money the insurance company has re-reimbursed.

 

[thomas7331]

Yes with out of network provider you can hold the patient responsible to the amount of your charge the insurance company when you bill out the claim. Even if the EOB comes back from the insurance company with an allowed amount less than the charged amount you can still bill the difference to the patient. In this case the doctor does not have a contract with the insurance company and can charge any difference between your billed amount and the amount of money the insurance company has re-reimbursed.

In most cases this is true, but I'd just point out that if the plan is a Medicare or Medicaid replacement plan, this may not the case. If your provider is out of network with a Medicare Advantage plan, for example, but treats a patient, the provider is required to accept the plan terms unless the patient is notified in advance. But for commercial insurance plans, you may balance bill the patient if the provider is not contracted with that plan.

 

[Cavalier40]

I might also add that many out of network claims are repriced via a 3rd party fee negotiator. If there is an agreed amount, then by the terms of the agreement, you cannot balance bill. They will also at times claims will be reviewed by a "bill review program" which will also not allow the balance bill. In 95% of cases however, the Remittance Advice will have a CARC code of PR 45 which is the amount above the allowed which can be applied to patient responsibility.

 

[CodingKing]

Was there was any SCA done for a limited number of sessions pending contract/credentialing? If so that may make a difference as to the answer. I know for example Beacon Health will do things like that and part of the SCA stated no balance billing.