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  • 1.  billing rejection with non contracted insurance company

    Posted 01-25-2021 15:37
    ​​We are starting to see eob's come thru from a non-contracted insurance company saying:

    Charges exceeding the plan's allowable claim limit of 155% of the Medicare allowed amount are denied as stated in the exclusions and limitations of the plan document. Patient is not responsible.

    Usually if we are not contracted with the insurance company. we don't do the write off and it becomes patient responsibility.

    To my knowledge, if we don't have a contact with the Insurance company, we can patient bill. We are starting to see a lot of the above come thru and I wanted to see if anyone else is having this same issue?

    Thanks and any help or suggestion is appreciated.

    ------------------------------
    Melissa Wissler
    Office Manager
    Richmond Radiologists, Inc.
    Richmond IN
    (765)966-2929
    ------------------------------


  • 2.  RE: billing rejection with non contracted insurance company

    Posted 01-25-2021 15:48

    We see a lot of these here in our area. They call it Reference Based Pricing and these carriers/plans pay the same amount regardless of network so it allows the patient to get services anywhere.

    You need to look at the insurance cards closely. What we have seen is the back of the card will state that if the provider submits a claim and accept assignment of benefits then you agree to accept their rates and not balance bill the patient so by sending a claim to them marked ACCEPT ASSIGNMENT you consented and agreed to their terms and rates.

     

    Maybe one of the legal experts can chime in and offer advises but I was told it would be easy/cheaper on us to accept it than try and fight them if the patient doesn't pay or they contact you because you balance billed one of their patients.

     

    I have a screen shot of one of those cards but I didn't attach it to the email because I didn't know if it would go thru.

     

     

     

    RESPECTFULLY, 

     

    Rick D Gladish, RCC, CPC

    MD Revenue Management, LLC

    111 Troy St STE F

    Tupelo, MS 38804

    ph 662-620-7102 fax 662-620-7106

    email: rick@mdrm.us

    website: www.mdrm.us

     

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