To be certain that we are talking about the same thing, when the practice does not accept assignment, there is no adjustments and the practice balance bills.
For example, Medicare approves $100 for a $120 charge and pays $80, this practice will then balance bill for the $40 to the secondary and anything that is outstanding is billed to the patient.
In the Batch Payment module, enter zero in the Adjustment Amount column. The Billing Manager will then set up the balance for billing to the secondary. After posting the secondary insurance payment, again don’t adjust any amount and then it is set up to go to patient billing after the “needs secondary box” has been checked.
You are correct about the limiting charge. Early in the 1980’s practices in all states were permitted to balance bill. Shortly after that, the limiting charge provision began in our state. Apparently this has become a national policy. Thanks for the correction.
Sarah,
To discourage non-participating practices from charging what Medicare considers to be “exorbitant” prices, a cap was placed, namely the limiting charge.
So in the example I gave, because of the limiting charge, the practice can only bill $109.25 in toto; if the approved amount is $95. The secondary insurance will pay $19.
If the practice does not accept assignment from the secondary insurance, the $19 will be sent to the patient as was the case with the Medicare payment. The secondary insurance payment will not likely to be more if the practice does not participate, because most secondary insurances will follow the lead of Medicare.
All payments will be sent to the patient. The practice can then bill the patient for $109.25. Posting this payment will require the adjustment of $10.75.
Patients in general and Medicare patients in particular are confused by insurance payments sent to them. The ideas of participation and assignment are very confusing for them (and for us, too). They just want to know what is left over. Often they are frustrated when they are sent a statement because if they have Medicare and Medigap, they think that there should be no balance.