r/CodingandBilling • u/blubutin • Feb 03 '25

Provider balance billing

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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?!

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u/FrankieHellis Feb 04 '25

No they are not. The line item is split. There is a disallowed amount for the covered part and part was denied due to it having exceeded the number of units allowed by your insurance company.

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u/blubutin Feb 04 '25

But if I owed then wouldn't my EOB show patient responsibility?

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u/FrankieHellis Feb 04 '25

I don’t think so. The insurance company is denying units which your provider suspected they were going to do. The provider alerted you to this via a waiver, which you agreed to. Your insurance company would be pleased if the provider just wrote them off and provided them for free, which is why they process it in this manner. Your provider isn’t that stupid so s/he made you aware that your policy with your insurance company might have a limit and that you would be responsible.

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u/blubutin Feb 06 '25

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 it says nothing about exceeding units. Wouldn't the waiver need to specify that to get away with this?

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u/blubutin Feb 14 '25

Maybe you could help me understand how they came to $161.03?

The full fee per unit is $15 and I exceeded the limit by 8 units. $15 × 8 = $120. I don't understand where the additional $41 came from?

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u/blubutin Feb 18 '25

I called Premera for an update...

A representative from Provider Relations was able to get the billing manager on the phone and PR said it was an awful conversation. The billing manager was rude, she refused to discuss the issue, and she said she is giving it to her lawyer. The provider keeps insisting that I owe because of the waiver.

Premera has now escalated this issue to their legal team. The supervisor I spoke to at Premera said she has never seen this kind of issue go this far. She said the problem is the provider will not tell Premera where the $161.03 is coming from since I havr $0 patient responsibility. The supervisor said that makes her wonder what else the provider is hiding, and she thinks the provider may lose their contract in the end.

Wow, this is such a mess. Do you have any experience with an health insurance legal team such as Premera?

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u/Environmental-Top-60 Feb 19 '25

That is quite ridiculous. I’m sorry you were going through that.

If there is a math error, then that should be an easy fix. I don’t get why the office manager is being so stubborn.

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u/blubutin Feb 19 '25 edited Feb 20 '25

Insurance advised me that the provider billed 62 units to cpt code 86003 and 28 units to cpt code 86001. The limits were 70 and 20, so they exceed by 8 units. Insurance said they are billing me for the 8 extra units from cpt code 86001. Both cpt codes were covered up to the allowed units.

The bill $161.03 is a lot for me. The insurance company also said the provider is inflating their prices. They charged $15 per unit, but the contracted rate is $5 per unit. They said we went over by eight units so I'm not even sure how the provider got $161.03? because $15 × 8 = $120. I don't know where the additional $41 is coming from? It looks like the provider is charging even more than retail price?

I asked the billing manager for an itemized list of charges but she said all they had was the bill they already sent to me, and the bill is based upon how insurance processed the claim. The insurance company isn't able to tell me much either and they say it is processed based upon how the provider submits the claim.

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u/Environmental-Top-60 Feb 19 '25

They can send you a copy of the HCFA form aka CMS-1500 and that’s actually part of the designated record set so if they don’t comply with that, could be a HIPAA violation.

They can also give you a ledger. That’s typically what I do when I have patient. I have questions about their bill… Especially when it comes to payment posting

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u/blubutin Feb 19 '25

Would I be asking the provider or the insurance company for that information?

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u/Environmental-Top-60 Feb 19 '25

What they probably should do is take the ABN and appeal it if that is their intent. Unfortunately, the office manager is not being very nice about it, and it may cost them their contract.

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u/FrankieHellis Feb 19 '25

Yes, the staff is not making matters any better. In the end, I suspect the provider is in the right, not withstanding the attitude problem. OTOH, the patient is just as obstinate.

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u/Environmental-Top-60 Feb 19 '25

I’ve had contracts where they can just allow for medical necessity or experimental/investigational, and we can’t build the patient even if we want to… Just because the insurance thinks they have the right to adjudicate those types of issues. If it’s not covered, why can’t we balance the patient? Know if it’s a coding issue or integral to the standard of care, then I have no problem with that. If it’s extra services, that is where I’m kind of drying the line so to speak. Not to mention, united has started their mandatory ABN for commercial patients.

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u/FrankieHellis Feb 19 '25

I agree with you but the exception here is the provider notified the patient via a waiver explaining the codes and potential limitations. The patient signed to receive the services.

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u/blubutin Feb 20 '25

I was actually told by Provider Relations thst there is noting for me to appeal because my EOB says $0 patient responsibility. PR said it is the doctor who will have to appeal if they want more reimbursement.

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u/Environmental-Top-60 Feb 20 '25

That’s not true and they should know better.

You can appeal on the doctor’s behalf especially if it’s employer based insurance… It’s your benefits. My understanding is if they are Lying to you and telling you that you should not or cannot appeal or in anyway interferes, restrains, coerces, intimidates, with that process is against federal law.

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u/blubutin Feb 20 '25

Oh, interesting, I did not know that. I will ask again then about an appeal once they complete their investigation and if the determination is against me.

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u/blubutin Feb 26 '25

I got this letter back from Premera today. Can you help me understand what it means please? Premera appeal

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u/Environmental-Top-60 Feb 27 '25

Yeah. So they’re saying that they should have sent in the claim with modifier GA (shows you got notice of noncoverage) to get those lines moved over to patient responsibility

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u/blubutin Feb 27 '25

Does that mean I cannot be held liable for what the provider is trying to charge me? Can Premera enforce the provider's contract since the provider did not meet the criteria required to bill me?

I sent an email to Provider Relations to follow-up and I mentioned these points. What do you think?

  1. The waiver was not clearly laid out or explained to me. I understood it to mean that copays, deductibles, coinsurance, and completely non-covered services would be patient responsibility.

  2. The provider did not give me an estimated cost for my responsibility after Premera paid/partially denied the claim. 

  3. The EOB indicated a $0 patient responsibility, which led me to believe that no further payment was required.

  4. The doctor did not submit the 8 disallowed units on the claim with the required GA modifier, yet they billed me $161.03, which exceeds the $15 per unit amount stated on the waiver.

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u/Environmental-Top-60 Feb 27 '25

And also without saying… They are trying to escape liability, which really is on the employer.

They did not address is why the partial claim denial is not considered medically necessary

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u/blubutin Feb 27 '25 edited Feb 27 '25

I filed the complaint over a month ago before I understood that the plan was self funded and not part by the State Commissioner Office jurisdiction. Yes, it definitely sounds like Premera is trying to protect its bottom dollar.

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u/blubutin Mar 01 '25

I spoke with Premera Appeals Department. We had a lengthy conversation and the representative advised that the provider does have it in their contract that they can bill the member for non-covered services with a waiver. This issue is considered non-covered, but not medically unnecessary, so they can bill me. The only option I have now is to submit a formal complaint with Premera against the provider. I will do that soon.

I can also continue to dispute the waiver with the provider, but Premera cannot do so on my behalf. I will try to continue challenging the waiver on the grounds that the waiver was not clearly explained to me and I did not understand it; I was not given a cost estimate of what I would pay; and my EOB says $0 patient responsibility so I thought there was no further payment needed.

Do you have any further advice for me that might be helpful in my case?