Patient Balances: Are Carriers Calculating the Patient Payment Correctly?

Patient payments are on the rise.

You know it and statistics support it. According to AthenaHealth PayerView 2012, the weighted Provider Collection Burden increased by 7 percent from 2010 – 2011 from 16.7 percent to 17.8 percent. Where is it headed in 2013?

Higher, of course!

Because the patient collection burden is frequently difficult to calculate, patients invariably question the balance. Further, some patient balances may not seem consistent with the information obtained during the verification and/or eligibility check. It is important to have a request letter seeking clarification from the carrier regarding the patient deductible/co-pay calculations. Such a letter can be very effective for the following scenarios:

  • Your office verifies benefits and was told there was a much lower patient responsibility to collect
  • The patient states that the patient responsibility is incorrect and/or the out-of-pocket requirement has been previously satisfied

Provider can use the following inquiry to initiate a review of the carrier’s calculation of the patient/insured financial responsibility:

Appeals and/or Claim Review,

It is our understanding that this claim was fully or partially denied due to patient copayment/deductible calculation. The explanation of benefits did not give adequate information to establish the accuracy of this decision. Therefore, please provide the following information to clarify the patient balance calculation.

This appeal is to request an audit of benefits applied toward the dates of service in question in order to verify that the patient portion complies with the policy or plan provisions. Further, if the patient balance is calculated based on previously paid claims, we appreciate clarification regarding the date the previous benefits were paid, the amount of payment and to whom the benefits were released. This information will assist with our verification of the patient balance accuracy.

State and federal disclosure laws as well as contract terms may be applicable and require the release of detailed information to substantiate an adverse benefit determination. If you believe this request does not fall under disclosure requirements, please provide a written explanation.

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