Click here for more sample CPC practice exam questions with Full Rationale Answers

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Click here for more sample CPC practice exam questions and answers with full rationale

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Click here for more sample CPC practice exam questions and answers with full rationale

Get Over the Pitfalls of Out-of-network Surprise, Balance Billing

Hurdles set by commercial carriers require out-of-network groups to tighten billing management and foster full financial transparency. Most non-participating providers learn that out-of-network reimbursement can be higher than in-network reimbursement. The two drawbacks to remaining out of network — higher patient out-of-pocket costs and exclusion from participating provider listings — may be remedied by waiving […]

The post Get Over the Pitfalls of Out-of-network Surprise, Balance Billing appeared first on AAPC Knowledge Center.

AAPC Knowledge Center

Balance Billing when a gap/out of network waiver is approved?

Hello. Can someone help me? Our office is out of network with a few insurance companies which causes us to request a Gap Exception/Waiver , which authorizes us to be in network for a certain procedure they need. My question is, are we able to balance bill after insurance pays? The explanation of benefits usually states the patient responsibility is zero or just the copay, although I am being told I can tell the insurance company we want to balance bill them when requesting the gap? I thought the reason to get the waiver was to minimize patient responsibility?

Medical Billing and Coding Forum

Balance billing

Other web searches suggest that balance billing is legal for an out-of-network provider in an office setting. Wondering if anyone can confirm or deny. Ya know, I trust Dr Google only so much. The patient knew the provider was out-of-network, though in this case both pt and provider were hoping the payor would credential the provider sooner rather than later so a number of visits went unpaid ($ 0 for out-of-network for this payor). All knowledge welcome.
Marjorie in Massachusetts

Medical Billing and Coding Forum

“Balance Billing” Secondary, ok?

If you are in network with the primary, who generally has significantly less allowables are you required to apply those adjustments before sending to secondary? Office is in network with both insurances however unsure on what we are allowed to bill to the secondary, just what prim puts as PR or entire remaining balance of charges?

Medical Billing and Coding Forum

Out of Network Balance Billing

I work for a substance abuse billing company in which our clients are 100% out of network will all insurances. They do not bill Medicare since free standing substance abuse facilities are a non covered entity.

My companies policy is to balance bill everything (unless the price was negotiated by a 3rd party pricing company like Multiplan)

I have argued to my superiors that since we check yes on provider accept assignment on our claims that we are allowed to write off the balance up to the out of network allowable or usual and customary rate (which can be calculated on any remittance) My superiors say that is fee forgiveness. I disagree. Shouldn’t we be able to write off the balance bill as long as we bill the patient the deductibles, copays and coinsurances that are assigned by the payer?

Medical Billing and Coding Forum