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Patient Responsibility

Norelie Posted Wed 19th of November, 2014 11:14:33 AM

We billed an office visit for a patient and was seen by a provider in our office that was out of her network. Instead of paying a $30 copay for an in-network provider, the insurance said she needed to pay $50. The patient doesn't think the difference is their responsibility. What is the right when our verification is incorrect in these situations? Is it a write off?

SuperCoder Answered Wed 19th of November, 2014 11:38:17 AM

Thanks for your question. Did the patient provide your office with the correct insurance information? If you verified benefits based on the correct insurance and the patient was told in error by your office staff that the office was in-network and that their portion would be based on the in-network rate, you should honor that. You should inform the patient that this is a one time adjustment and that going forward the rate would be based on the out-of-network benefits. Doing these types of adjustments on a routine basis could constitute as a violation of your contract with the insurance company. If the patient provided incorrect insurance information, and you based your verification on that information, the patient should be held responsible. Ultimately the patient should be aware of which providers are in-network. Most insurance companies have web tools as well as customer service representatives that can provide that information. Hope this helps.

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