Can I balance bill a patient for the amount not paid by the insurance carrier?

Sometimes, depending on what was not paid and the reason.

For example, patients are responsible to pay you for co-pays, deductibles and coinsurance portions that are not paid by the insurance carrier. The patient may also be billed for items that are specifically not covered by the insurance plan, i.e. vitamins, cervical pillows, massages, etc. However, you must let the patient know in advance and in writing that certain items may not be covered and will be the patient's financial responsibility.

The patient is not responsible for the portion of the claim that is denied due to PPO or network discounts. As a participating provider, you are agreeing to a fee schedule that is set by the PPO network and is approved by AHC. If your charge for a particular CPT code is over the fee schedule, the insurance carrier or claims administrator may deny a portion of your claim. You cannot bill the patient for the portion of the claim denied for this reason.

However, benefit plans often have limits on chiropractic care. Some plans limit the maximum benefit payable per visit, some limit the number of visits per benefit year and some limit both. You can bill the patient for claims that exceed the plan limits, up to the fee schedule amount for the services rendered. For example, if the services add up to $75 and the fee schedule for the services adds up to $58, the plan limit might be only $50 per visit. The patient is still responsible for the additional $8, if you choose to hold them responsible for it. Again, you should let the patient know in advance and in writing that they may be responsible for certain items and for services that exceed their plan limits. Our bulk pay remittance will distinguish between PPO or Network discounts and plan limits.

Some insurance plans require pre-certification of treatments, especially HMOs. You have an obligation to follow the rules of the patient's insurance plan. If you fail to obtain pre-certification and it is required, your claim might be denied. The patient and the plan will expect you to write off this type of denial. With that in mind, be sure to get clear answers to questions when verifying benefits.

And finally, some patients will change carriers and not notify you. They may provide you with the incorrect information. While you have an obligation to file claims in a timely manner, you cannot do so without the patient providing correct information. If the claim is denied because the patient did not provide accurate information, but you acted in good faith, you should balance bill the patient.