Wiki Insurance denial for additional information

[pchamp25]

I work in an ASC and I am looking for information on whether a patient can be billed if the insurance is requesting additional information and it is not received. Example, we submit an claim and the EOB we receive back is a denial/no payment and it's because the patient needs to submit a questionnaire and additional information is needed. We have been having issues getting patient's to complete what's needed therefore leaving the claims outstanding in our A/R. If we do not receive a response, are we able to bill the patient the full cost of the claim even if it states $0.00 under patient responsibility? Just looking for clarification and how other practices handle this situation. TIA

 

[lorettah]

I have always had the insurance say that ultimately the patient is responsible and to send the bill to the patient. I feel like it is usually worth the time and effort to reach out to the patient and explain the situation, and what they need to do. Some patients get those letters, but ignore them, because they don't understand what they should be doing. But depending on your manpower and volume, you might not have time for that. The balance might be patient responsibility, but if the patient never pays the bill then you are still out the payment.

 

[csperoni]

My recollection from working those types of denials is that the claim usually first gets "pended" for the info. If not received by a particular deadline (approx 30-45 days), then the claim is processed and denied, with patient responsibility on the EOB.
We would call the patient when notified of pending and explain they should return the questionnaire and/or contact their insurance. A week or 2 later, a second contact to the patient (call or form letter). Both times, we would warn the patient if they did not follow their insurance guideline, they could owe $####.
Once the claim was processed, either:
1. Patient sent the info and claim processed/paid as per contract
2. Patient did not send, and we would bill patient.
Just remember, if the patient was non-compliant about sending the requested info to the insurance, the probability of them paying your bill is quite slim.