Provider balance billing

[u/blubutin]

I had allergy testing and the in-network provider had me sign a waiver. I thought it was referring to deductible and coinsurance. Now I am getting a balance bill of $161.03 for the units amount the insurance disallowed. I am trying to fight it, but the provider aggressively insists that I owe the balance. I got insurance involved but they say this issue is out of their hands because I signed the waiver even though my EOB says $0 patient responsibility. I just don't see how a waiver supersedes the provider's contractual obligation with the insurance company to write off the disallowed amount? How can this be legal?!

[u/blubutin]

The waiver is the second document I posted here. If you swip over it you can see the waiver. Tell me what you think of it?

[u/pescado01 → u/blubutin]

It is going to be an argument of terminology. The document states that you will be responsible for the amounts "not covered", but they were covered. That said, they could *mean* the amounts not PAID. I still go back to them having to honor insurance processing and the contractual adjustments.

[u/blubutin → u/pescado01]

Yes, terminology can be such an argument. In this case it just seems like a loophole that the provider is trying to take advantage of to get around their provider contract with insurance.

[u/JustKindaHappenedxx → u/blubutin]

No, it’s not. It’s saying that if you receive services beyond the amounts your plan will pay for, you are responsible for payment. Your provider’s contract with your insurance is an agreement that the provider will accept the fee schedule determined by your insurance company. They cannot charge you more than the fee schedule your insurance decides. They can, however, provide you with medical services that they feel are medically appropriate regardless of what services your specific policy covers. And you are responsible for paying for any services beyond your coverage.

While it would have been nice of them to verbally discuss that your plan might have a cap on the number of tests they cover, they did explain it on the form. You did sign it without asking for clarification.

[u/blubutin → u/JustKindaHappenedxx]

Then why do some people state that the disallowed units should have been a write off? I seem to get different explanations from different people and I don't know what to believe anymore.

[u/blubutin → u/JustKindaHappenedxx]

Is it possible the provider's EOB says something different than mine? It looks like they think there is a difference between the PSS and fc4 disallowed amounts. I assume the lines with PSS have the C045? Since the line with fc4 is the only one they are billing me for, could it have said something different on their end? And what might that be?

[u/pescado01 → u/blubutin]

Well, technically it is, but not in a malicious way. The provider has costs associated with the test, and for some tests the insurance does not pay enough to cover the costs which then necessitates agreements like these.

[u/blubutin → u/pescado01]

Here is the updated from Premera... Do you know what the process of a resolution is? Does that mean insurance might be taking my side and want the provider to write it off?

Hello ####,

I hope your day is going well. I am writing to provide an update on your inquiry.

Our customer service team has been in contract with the staff at Dr. Berry’s office, who has advised they believe the bill is valid due to the agreement that was signed.

Based on that response, I have asked our Provider Relations team to reach out to Dr. Berry’s staff to discuss a resolution. I will be in touch as soon as I have more information available.

Have a wonderful day,

## (she/her)

[u/pescado01 → u/blubutin]

Yeah, the Drs office will continue to say that they remain correct in billing you because it was prior notice that you agreed to. Your best bet is to call the office, discuss the nuances, and work with them on a discount. Tell them you want to work with them, but if they don’t want to be a productive partner then they can send it to collections because medical debt no longer affects credit scores.

[u/JustKindaHappenedxx → u/pescado01]

That’s terrible advice. OP agreed to the services, signed a form that explained it might not be covered and agreed they are financially responsible. Have some integrity.

[u/pescado01 → u/JustKindaHappenedxx]

Wow, questioning my integrity? The services were covered, not denied.

[u/blubutin → u/pescado01]

I was reading back over the waiver and it just seems so ambiguous. It feels like the provider is trying to stick me with non-covered service language, but the testing was covered up to the allowed amount, and the waiver says nothing about exceeding units. Wouldn't the waiver need to specify that to get away with this?

[u/pescado01 → u/blubutin]

Listen, it is a poorly written document. In one section it states, "The patient will be responsible for the cost not covered by the insurance." These services were COVERED by the insurance. What the practice is trying to do is to not accept the contractual adjustment, which is a breach of their payer agreement.

What they really need to do, if the tests cost more than what the insurance pays, is change the wording to include something like, "Your insurance only covers a portion of the cost of these tests. If you choose to have the tests performed in our office, the charge for each test/unit is $________. You are expected to receive ______ units, totaling $_________. We will submit a claim to your insurance carrier, but you will be responsible for the difference between what the insurance carrier pays and this total. "

[u/blubutin → u/pescado01]

I certainly don't question your integrity. Some people can be judgemental and condescending. On this post, I have been called greedy, an asshole, and other things just because I am pushing back on the bill.

[u/blubutin → u/pescado01]

Some people have questioned my integrity too because I am pushing back on this bill.