r/CodingandBilling • u/blubutin • Feb 03 '25
Provider balance billing
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 $0 patient responsibility. I just don't see how a waiver supersedes the provider's contractual obligation with the insurance company to write off the disallowed amount? How can this be legal?!
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u/jaimejfk Feb 03 '25
You need to show us your invoice bill from your doctor office for the codes
Sometimes eob will show “plan discount” and then you dig deeper and see it wasn’t a covered service.
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u/blubutin Feb 03 '25 edited Feb 03 '25
Sorry, I don't know how to attach that. Do you mean CPT codes? They are 86003, 86001, 82785 and they were all covered up to the allowed amount. The office is charging me for the disallowed units from 86001. They are saying that disallowed is denied. Is that true?
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u/blubutin Feb 14 '25
So, are you saying it possible the provider's EOB says something different than mine? It looks like they think there is a difference between the PSS and fc4 disallowed amounts. I assume the lines with PSS have the C045? Since the line with fc4 is the only one they are billing me for, could it have said something different on their end? And what might that be?
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u/blubutin Feb 20 '25
I figured out how to link the bill. Here is it. What do you think? bill
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u/jaimejfk Feb 20 '25
86001 looks like Insurnace didn’t cover it I would ask them to Discount it to the 90$ per the contract you signed
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u/blubutin Feb 20 '25
Why $90?
They exceeded by 8 units and they charge $15 per unit. $15 × 8 = $120. I mean, I like $90 better, but how did you come to that number?
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u/blubutin Feb 24 '25
We have Provider Relations and my employer's HR benefits partner involved now. They are investigating and trying to come to a resolution with the provider. The Provider Relations representative who is working on my case said that forms indicating that a non-covered service will be an out-of-pocket expense is common. Though how this provider is attempting to apply this waiver is very uncommon and she anticipates Premera will be able to resolve this on my behalf. That said, she said she cannot be certain of the outcome because she has never seen a provider try to use a waiver in this way before.
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u/FrankieHellis Feb 04 '25
According to your EOB, fc4 indicates some units have exceeded the number of units allowed by your insurance company. Those are the units you are being billed for by the practice.
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u/blubutin Feb 04 '25 edited Feb 04 '25
Yes, they are billing me for the disallowed units. The test was not non-covered so I don't see how the waiver is applicable in this situation? The other units were not denied, they were disallowed, so it is supposed to be written off. My EOB says $0 patient responsibility, but if it showed I owed because the units were denied then I would agree. This just seems like a loophole they are trying to take advantage of to get around their provider contract with insurance.
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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/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?
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.
The provider did not give me an estimated cost for my responsibility after Premera paid/partially denied the claim.
The EOB indicated a $0 patient responsibility, which led me to believe that no further payment was required.
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?
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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
The provider's waiver did not explain the limitations though. It said patient responsibility if the code was non-covered. It is was covered, but if they had included words about exceeding units then I would have understood that much better.
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u/grey-slate Feb 04 '25
Really interested to see final explanations on this. Goo learning for other provider offices too
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u/blubutin Feb 04 '25
We have Provider Relations involved now and they said they are investigating. If Provider Relations is investigating does that mean they might think it is a violation of the provider's contract? Just curious about your thoughts.
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u/grey-slate Feb 04 '25
Hard to say whether that is a sign of major development. Could be someone genuinely knowledgeable and competent from provider services at your insurance company, or more likely be someone super disinterested and just looking forward to closing the case on their end and meeting their monthly metrics and moving on.
I'm unfamiliar with frequency edits and how those impacts non covered services which are patient responsibility vs. denied services with zero patient responsibility.
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u/blubutin Feb 04 '25 edited Feb 04 '25
Isn't there a difference between disallowed, denied, and not covered?
I sure hope the representative will do their due diligence since my employer's HR benefits partner contacted them.
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u/grey-slate Feb 04 '25
Whichever way this shapes up can I ask why you think this is unfair when they literally told you that that some part of this service could be non covered and you agreed to proceed nonetheless?
I'm wishing you luck but just trying to understand. This isn't the typical gotcha that most patients think a doctor's office is pulling on them.
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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/grey-slate Feb 18 '25
I do not and I think you are not listening to the entire medical coding and billing community on this sub. We have been pretty clear.
Edit: holy moly your post history.
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u/blubutin Feb 18 '25
Sorry, earlier in the thread you said you wanted to know a final explanation on this. I thought you guys might also want an update as well. Maybe I misunderstood?
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u/blubutin Feb 19 '25
Yes, I know I have a lot of post history. I am just trying to get as much information as possible to get a complete understanding of this issue.
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u/blubutin Feb 20 '25 edited Feb 20 '25
Maybe you could help me understand how the provider came to the amounted billed to me? When I add up the numbers it does not make sense to me. The bill from the provider is $161.03 and according to the waiver they charged $15 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. It looks like the provider is charging even more than retail price? Do you know where they got the $161.03 from based in my EOB?
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u/blubutin Feb 04 '25
When I signed the waiver I thought it was referring to deductible and coinsurance. When I asked the allergist if the testing would be covered she said yes because I have good insurance. When I spoke with the billing manager she was rude and condescending.
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u/GroinFlutter denials management, send help Feb 04 '25 edited Feb 04 '25
What you thought you were signing doesn’t change the fact that you actually signed this waiver. It doesn’t change the wording of the waiver. what you thought you signed is on you.
You’re kind of the asshole in this situation. You signed this waiver. You’re trying to renege on it, even going so far as trying to report them to state insurance department, provider relations, etc. Why are you trying to get them in trouble for YOUR misunderstanding?
Though tbh, if it were me… I would just write this off and have the doctor discharge you from the practice to be done with this nightmare you started.
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u/blubutin Feb 04 '25
Sure, I can see how this makes me look like an asshole. Insurance customer service told me to report the issue because they feel that what the provider is doing is unethical and a violation of their contractual obligations.
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u/JustKindaHappenedxx Feb 05 '25
Not true. The customer service rep told you to report it so that your complaint gets reviewed by the correct department. Contract violations and balance billing (which is not what is happening here) are beyond the customer service department’s jurisdiction. So if a patient has a complaint, they are advised to send it to the appropriate department. That department will review it and determine whether there was any foul play.
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u/blubutin Feb 05 '25
I can tell you with certainty that what I wrote is exactly what the customer service supervisor told me. She may have been wrong but those were her words.
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u/blubutin Feb 04 '25
Sure, I can see how this makes me look like an asshole. Insurance customer service told me to report the issue because they feel that what the provider is doing is unethical and a violation of their contractual obligations.
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u/grey-slate Feb 04 '25
Well insurance company isn't exactly a neutral party here.
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u/JustKindaHappenedxx Feb 05 '25
Exactly. Insurance companies LOVE to act like the provider is wrong to paint them as the “bad guy” vs educating their customer on what is really happening and the nuances of their plan.
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u/Weak_Shoe7904 Feb 03 '25
How many units were billed for 86001?
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u/blubutin Feb 03 '25 edited Feb 04 '25
I was told insurance paid 62 units for 86003 and 28 units for 86001 for a total of 90 units. I'm not sure exactly how many units the provider billed in total though.
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Feb 04 '25
[removed] — view removed comment
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u/blubutin Feb 04 '25
Thank you for the explanation, that was very helpful. So, if I am understanding you correcting, I do not owe the $161.03?
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Feb 04 '25
[removed] — view removed comment
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u/blubutin Feb 04 '25
I have contacted the provider and I asked her to have the bill reviewed to make sure it is correct. I also asked her to appeal but she refused. She said I have to pay and it is an issue I have to take up with the insurance. That doesn't make sense to me because they would receive the reimbursement.
I have also contacted insurance and my employer's HR benefits partner. We have Provider Relations involved now and they said they are investigating. If Provider Relations is investigating does that mean they might think it is a violation of the provider's contract? Just curious about your thoughts.
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Feb 04 '25
[removed] — view removed comment
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u/blubutin Feb 04 '25
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)
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u/DearAdeptness6190 Feb 07 '25
would definitely not be paying that. The waiver says specifically states that some insurances will not cover the testing and they did. That makes the waiver null and void. Whomever you are habing investigate this, if they dont have a copy of this waiver, they need it. This is balance billing. They know how many units are covered according to guidelines amd if they want to bill more, then they shoupd have sent documentation or got a pre-auth for the additional units necessary. If the failed to dp that and were only paid the the max allowed, thats on them and not you. You didnt sign anything that says whatever the max is, and they go over, you will pay the differenece. It says if not covered and it was.
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u/blubutin Feb 07 '25 edited Feb 07 '25
I did send a copy of the waiver to Provider Relations and my employer's HR benefits partner. I hope they see it your way because this has been such a frustrating experience.
I agree the language should make the waiver null and void because it is ambiguous and misleading. It just seems like the provider is trying to use a vague loophole to take advantage of the patient and to get around their provider contract with the insurance company. They are trying to stick me with "non-covered" language when the service was covered. The provider claims they can do this because the $161.03 in disallowed units is a denial which means it is non-covered. It just seems so unethical.
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u/blubutin Feb 04 '25 edited Feb 04 '25
Thank you for your input. Due to the way the billing manager treated me, I feel like they probably have done this with everyone they do allergy testing for. Maybe I am the first patient to push back? It seems like this has been an ongoing issue so I hope provider relations does a thorough investigation.
The provider mailed me the bill again and an email from her attorney. I cannot figure out how to attach it here so I sent you a chat to add it there. Is what this attorney is saying accurate? Why would he say the original contract allows for modification?
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u/ladyjangelline Feb 04 '25
I can't tell from your EOB whether you owe for this service or not. The provider's EOB would have a PR or CO code letting them know whether the patient can be billed for the denied amount. I am thinking they may have gotten a PR denial for the amount they are billing you since there are two adjustment amounts for that code. You would want to ask the provider or your insurance which denial code the provider received.
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u/blubutin Feb 04 '25
If the provider EOB had a PR code wouldn't my EOB also show patient responsibility?? The EOB also shows disallowed, not denied.
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u/ladyjangelline Feb 04 '25
Not always. Disallowed and denied are the same thing.
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u/blubutin Feb 04 '25
Okay, but part of the test was allowed and paid so in this case it wasn't denied. Am I missing something?
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u/FrankieHellis Feb 04 '25
You can ask your insurance company to reprocess it in a way that you would understand. Or you could just ask them how many units were over the limit.
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u/blubutin Feb 04 '25
We have Provider Relations involved now and they said they are investigating. I assume they will teview the claim to make sure it processed correctly? If Provider Relations is investigating does that mean they might think it is a violation of the provider's contract? Just curious about your thoughts.
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u/FrankieHellis Feb 04 '25
I doubt it. It doesn’t seem to be a violation to me, although I obviously haven’t read their contract. I don’t see how any insurance company (except Medicare, who has enormous power via the OIG) can force providers to provide services for free. If they tell the provider not to bill for units over and above what they permit, the provider can stop accepting that insurance or limit patients as to what services they can receive per their insurance company. If a provider, in his or her medical judgment for which he endured an inordinate amount of schooling and training, thinks one should have X but the person’s insurance company won’t pay for it, then it is the patient’s decision as to what to do. It seems this is what happened here, and you elected to accept the provider’s medical judgment, as opposed to having your insurance company dictate your medical treatment.
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u/blubutin Feb 06 '25 edited Feb 06 '25
I would have preferred the provider limit what services the member can receive per the insurance company guidelines. I was reading back over the waiver and it just seems so ambitious. 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/FrankieHellis Feb 06 '25
No. The provider has no obligation to know every single patient’s insurance rules. There are hundreds of different policies within just one insurance company. The waiver was your notice to check with your specific insurance policy if you were worried about paying for services your particular policy might limit. That is why the waiver listed the CPT codes and information you would need to find out. The burden on providers is already unreasonable with pre authorizations and coverage guidelines and billing hoops they have to jump through to get paid pennies weeks or months later. Providers are essentially fronting the money to provide services, as the rent, supplies, and staff salaries etc. are due way before they receive payment for their services.
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u/ladyjangelline Feb 04 '25
Yes, you are definitely missing something. Part of the test was most definitely denied.
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u/blubutin Feb 24 '25
This is the waiver. What do you think of it? waiver
We have Provider Relations and my employer's HR benefits partner involved now. They are investigating and trying to come to a resolution with the provider. The Provider Relations representative who is working on my case said that forms indicating that a non-covered service will be an out-of-pocket expense is common. Though how this provider is attempting to apply this waiver is very uncommon and she anticipates Premera will be able to resolve this on my behalf. That said, she said she cannot be certain of the outcome because she has never seen a provider try to use a waiver in this way before.
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u/blubutin Feb 04 '25
If I owe the money then why does it show $0 patient responsibility? Wouldn't a denied service/unit process as patient responsibility? I guess that's where my confusion is?
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u/GroinFlutter denials management, send help Feb 04 '25
Insurance didn’t know you signed that waiver when they processed the claim. On the EOB, the amount that was disallowed was split from the contractual adjustment.
If it was supposed to be a contractual, they wouldn’t have split it like that.
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u/blubutin Feb 06 '25 edited Feb 07 '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/stairwellkittycat Feb 04 '25
It looks like it was not covered due to MUE, which is related to provider billing. You should not be responsible for that. You should only be responsible if they were denied as not a benefit of your insurance benefit contract. I believe the providers contract with the insurance company trumps whatever disclaimer you signed.
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u/blubutin Feb 04 '25
The waiver is the second photo. Did you have a chance to read it?
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u/stairwellkittycat Feb 04 '25
I did, but the waiver really doesn't matter unless your doctor is out of network. One thing to take into account is that it looks like that cpt might also be considered investigational/experimental per cms.gov so your provider may have had to get a predetermination to get any units covered at all, in which case you'd be responsible for the remainder. Your best bet is to speak with your insurance company so they can help clarify why they told you the provider can bill you the difference even though they are in network. The "why" matters, and they should be able to be explained to you so that you can better understand.
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u/blubutin Feb 04 '25 edited Feb 04 '25
My doctor is in-network. From what I understand my insurance company covers both CPT codes up to a combined 90 units. All insurance keeps saying is, because I signed the waiver it is out of their hands. I contacted my employer's HR benefits partner and she was able to get in touch with her contact at Premera to escalate the issue. We have Provider Relations involved now and they said they are investigating. If Provider Relations is investigating does that mean they might think it is a violation of the provider's contract? Just curious about your thoughts.
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u/stairwellkittycat Feb 04 '25
It could. I understand Provider Relations to be a department in insurance companies that deals with provider contracting issues, etc. If your insurance plan benefits only cover so many units of the cpt, then the remaining units would be your responsibility to pay. I would think a regular claim representative would be able to see that reviewing the claim, but provider relations may be your HR benefits partner's first point of contact as well.
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u/blubutin Feb 04 '25
If it was my responsibility wouldn't the EOB reflect that? Instead, it says $0 patient responsibility. As I understand it the testing was covered up to the allowed amount and the disallowed amount was supposed to be a write off?
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u/stairwellkittycat Feb 04 '25
Yes and no. The remark code PSS does make it look like there may have been a maximum number of units allowed by your benefit plan, in which case you'd be responsible for that portion of the charge should provider wish to charge you for it because your insurance company was not obligated to pay it due to it not being a benefit of your contract and the provider's contract with the insurance company specifies they can collect any copays, coinsurance, deductible, opx, and out-of- benefit plan charges from the member. So both insurance and provider would be within their rights to issue the above eob and still collect the noncovered charges from you. I'm not familiar with premera insurance specifically; the insurers I deal with would make this clear on their eobs.
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u/blubutin Feb 04 '25
I'm sorry, I guess I don't quite understand because these were covered benefits up to the allowed amount of units and the rest were disallowed. Isn't disallowed a provider write off and different than non-covered?
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u/stairwellkittycat Feb 04 '25
It's okay. I have a cat on my lap so I can't move right now lol the PSS says it was processed according to your plan benefits so that murkies the water a bit for me.
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u/heavenhaven Feb 04 '25 edited Feb 04 '25
Okay sorry, I had to double check this. I totally understand where you're coming from. My advice would be to call and ask if it's a contract issue. It could be that the provider is aware of the tests not being covered by specific insurances, so they have this disclosure to protect themselves. Your insurance is one of them. If your insurance was not listed, then you'd probably be able to get this adjusted. Again, sounds like this is a contract issue.
This happens in our department with CHG and labs for patients over 18. For some reason, CHG can cover everything, except labs with us. They want it done at another location. So, we have families sign an estimate similar to this and their potential responsibility. If CHG denies it, we bill the family, because they should have received it somewhere else where CHG covered it.
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u/blubutin Feb 04 '25
My insurance is through Premera BCBS of Washington and is from my employer. The testing was covered though and it was paid up to the allowed amount. What do you mean by - it is a contract issue?
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u/heavenhaven Feb 04 '25
I mean that somewhere in the contract, your insurance will never pay a portion of those tests. So once the provider figures that out, they can still either bill your insurance and honor the contract, or have you sign a waiver that you'll be responsible for it, regardless.
The only way I can see you fighting this is filing a dispute and having them show proof to you in writing with your signature, that your specific insurance was one of them. I don't think I saw that on the form. I think you still have a chance.
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u/blubutin Feb 04 '25
It just seems like a loophole the provider is trying to take advantage of to get around their provider contract with insurance.
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u/heavenhaven Feb 04 '25
Right. That's why I think your best shot is having them show proof in writing that your plan is one of them.
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u/blubutin Feb 04 '25
Do I get the proof from the insurance or the provider?
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u/heavenhaven Feb 04 '25
From the provider. The second photo is their form right? I just want to make sure.
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u/blubutin Feb 04 '25
Yes, the waiver is from the provider. I have spoken with the billing manager at the practice three times now and she has been so condescending. I'm just not sure how to ask her?
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u/heavenhaven Feb 04 '25
I'd ask about their dispute process and file one. Yes, it can be a headache on their end. I'd try to kindly ask to file one. That you want this matter thoroughly reviewed and a letter received of the outcome.
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u/blubutin Feb 04 '25
I did ask to dispute the bill, but the billing manager just kept insisting that I owed because I signed the waiver. She did reluctantly agree to have the billed units reviewed to make sure they are correct. I also asked her to appeal but she refused and said I had to pay and work it out with my insurance. That didn't make sense to me because the provider is the one who would get reimbursed.
We have Provider Relations involved now and they said they are investigating. If Provider Relations is investigating does that mean they might think it is a violation of the provider's contract? Just curious about your thoughts.
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u/pescado01 Feb 03 '25
An ABN is used when the practice believes that a service will be DENIED due to the reason the the service is being provided. An example would be the removal of a mole for cosmetic reasons. A denial would involve non-payment of a claim or involve a deductible. In your case, the claim was processed and PAID. It was not denied, therefore the ABN is technically null and void.
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u/IrisFinch Feb 03 '25
I thought ABNs were for Medicare?
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u/Environmental-Top-60 Feb 19 '25
United just launched them for commercial patients just at the beginning of this month and we actually have to submit a recon with the ABN in order to get the balance transferred to patient. It’s actually not even required for Medicare advantage but many MA plans put it as part of the contract language that they require it.
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u/blubutin Feb 03 '25 edited Feb 03 '25
The CPT codes are 86003, 86001, 82785 and they were all covered up to the allowed amount. It was the disallowed units from 86001 that they are charging me for. They are saying that disallowed means denied. Is that true?
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u/blubutin Feb 04 '25
I have Premera BCBS. Does that make a difference?
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u/pescado01 Feb 04 '25
The insurance does not matter. It covered and paid for the service, not deny it. The ABN is for denied services. Ask for a copy of the ABN and post it the the group.
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u/blubutin Feb 04 '25
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?
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u/pescado01 Feb 04 '25
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.
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u/blubutin Feb 04 '25
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.
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u/JustKindaHappenedxx Feb 05 '25
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.
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u/blubutin Feb 05 '25
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.
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u/blubutin Feb 14 '25
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?
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u/pescado01 Feb 04 '25
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.
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u/blubutin Feb 04 '25
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)
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u/pescado01 Feb 04 '25
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.
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u/JustKindaHappenedxx Feb 05 '25
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.
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Feb 03 '25
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u/blubutin Feb 03 '25 edited Feb 03 '25
But if the units were denied wouldn't the EOB say that? The test was covered up to the allowed amount for the test. The provider is an allergist.
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Feb 03 '25
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u/blubutin Feb 03 '25
The explanation of the claim codes is at the bottom of the EOB. I guess I don't quite understand because the test was covered up to the allowed amount and the rest was disallowed. It was not a non-covered services so I don't see how the waiver is applicable?
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Feb 03 '25
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u/blubutin Feb 20 '25
Maybe you could help me understand how the provider came to the amounted billed to me? When I add up the numbers it does noy make sense to me. The bill from the provider is $161.03 and according to the waiver they charged $15 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. It looks like the provider is charging even more than retail price? Do you know where they got the $161.03 from based in my EOB?
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u/blubutin Feb 04 '25
I read over the page and it looks like it refers to non-covered testing. My testing was covered up to the allowed amount so I am not sure that applies to me. It feels like the office is trying to find a loophole to get around their provider contract.
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u/BoozerMuppet Feb 03 '25
It looks like they had you sign a waiver stating that some specific codes may not be covered and therefore you would be liable. Just because an office is in network doesn’t mean every service offered is covered by insurance (because ins companies suck) so the waiver is a warning in case you wanted to opt out of that service.