Wiki Balance billing

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namitasd@hotmail.com

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Scenario-

Billing is done by PCP (patient's PCP) for a service that the patient was not aware of and they are receiving a copayment or deductible. The patient had not signed the ABN or no other form was signed. The documentation supports what was billed. Patient is in network. The physician felt the service was needed and it was documented. However, the patient did not know it was being billed. A sick visit is documented and billed but patient didn’t know it was occurring.

The MD is in-network.

Would this be covered by "No-surprises bill" Act? Should the patient be balance billed?
 
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Why did the patient go to the physician's office? Did he/she think going to the doctor is free?
 
namitasd@hotmail.com said:
Patient came in for an annual wellness visit. A physical was billed as well as a sick visit.
Click to expand...

This is not balance billing. Balance billing is when the patient is charged for the difference between the provider's charges and the allowed amount. Being charged a copay for the E/M portion of a visit is not being balanced billed.

Also, you mentioned an ABN in your initial post - this isn't a situation where an ABN would be applicable.

Here's are some links from the AMA and the AAFP that discuss preventative and E/M services on the same visit. These links might be helpful to review:

www.ama-assn.org

Can physicians bill for both preventive and E/M services in the same visit?

This regulatory myth examines if physicians should bill for both preventive/wellness and evaluation and management (E/M) services when they are performed during the same visit.
www.ama-assn.org www.ama-assn.org



Was a separate and significantly identifiable E/M service performed and documented? (You mentioned that the E/M service was documented, so I am assuming yes.)

I'm not clear on whether you're the patient (or family member of a patient), or whether you work for the physician office.

If you're the patient, you may want to take a look at the practice's financial policy - sometimes a physician office's financial policy references preventative visits and office visits. Typically this would be signed when completing all the new patient paperwork before the first visit with the practice.
 
sls314 said:
This is not balance billing. Balance billing is when the patient is charged for the difference between the provider's charges and the allowed amount. Being charged a copay for the E/M portion of a visit is not being balanced billed.

Also, you mentioned an ABN in your initial post - this isn't a situation where an ABN would be applicable.

Here's are some links from the AMA and the AAFP that discuss preventative and E/M services on the same visit. These links might be helpful to review:

www.ama-assn.org

Can physicians bill for both preventive and E/M services in the same visit?

This regulatory myth examines if physicians should bill for both preventive/wellness and evaluation and management (E/M) services when they are performed during the same visit.
www.ama-assn.org www.ama-assn.org



Was a separate and significantly identifiable E/M service performed and documented? (You mentioned that the E/M service was documented, so I am assuming yes.)

I'm not clear on whether you're the patient (or family member of a patient), or whether you work for the physician office.

If you're the patient, you may want to take a look at the practice's financial policy - sometimes a physician office's financial policy references preventative visits and office visits. Typically this would be signed when completing all the new patient paperwork before the first visit with the practice.
Click to expand...
Thanks for the detailed explanation. I understand the concept of balance billing. The article above is great. I agree that preventative and sick office visit could be billed together. What normally is the path followed when the sick visit occurs without the patient's knowledge?
 
namitasd@hotmail.com said:
Thanks for the detailed explanation. I understand the concept of balance billing. The article above is great. I agree that preventative and sick office visit could be billed together. What normally is the path followed when the sick visit occurs without the patient's knowledge?
Click to expand...

I'm not clear on what you're asking about the visit occurring without the patient's knowledge. The patient was at the visit and part of the discussion about the medical issue, correct?

As I mentioned in my previous post, this is often addressed in the practice's financial policy. The patient would generally be given a copy and sign an acknowledgement of receiving the financial policy at their first visit with the practice. (Their very first visit with the practice, not necessarily this specific visit.)


Here are some examples of wording from various practice financial policies. You can take a look at the financial policy for your practice and see if there are similar statements:



• Well Visit and Problem Visits - If during the course of your preventive exam, the provider addresses a problem-related issue (i.e., itching, burning, depression, pain, rash, etc.) you may also receive an office visit charge. Your insurance may require you to pay a copay for the separate problem-visit charge on the same day.




It is your responsibility to be familiar with the specifics of your insurance policy regarding well care visits and office visits, including, but not limited to: copays, vaccine and doctor visit coverage, referral and authorization requirements for specialty care, radiology, lab tests, and emergency and/ or hospital care. Well care visits and office visits may be coded at the same appointment. (e.g., a patient seen for a well care visit but also treated for an ear infection)



Well women/annual visit and Problem/sick visit on the same day

  • Some insurance companies will cover well-woman/preventive/annual visits and some will not.
  • It is your responsibility to know what healthcare benefits your insurance covers, prior to your visit.
  • If you need to discuss any health problems that require evaluation and management (gynecological problem, surgery, etc.), this must be documented separately to your well woman visit and appropriately billed for.
  • Your insurance company will not pay for additional problems that are addressed during the well-woman/preventive/annual exam. You will need to make a separate appointment to discuss these problems with your physician.
  • Please do not ask our staff to change coding for the purpose of getting your insurance to make payment on services rendered.
 
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