All medical billers when you get an EOB that says this is disallowed?

Question

Does the balance become the patients responsibility?

Answer 1

if the insurance denied the whole charge then yes it is patients responsibility...

if they denied only part of the charge- a participating provider will usually write this balance off- a non par provider will bill the patient

if they denied the whole charge call your insurance to find out why, they may require some info from the patient or the doctor-- don't just ignore it- it may have been denied in error and you don't want to pay the entire balance if you don't have too......if you feel it should be a covered charge based on  your policy, appeal the denial.... if it is not a covered charge, and you cannot afford to pay the whole balance call the doctors office, they may take off a percentage if you pay immediately ...

I'm not entirely sure why the thumbs down! i deal with this stuff everyday!!!! A participating provider writes off the partial balance, a non participating provider may bill the patient and if the whole charge is denied you need to call your insurance company to find out why... that is the simplest way to put it

Answer 2

Sometimes yes, sometimes no. The EOB will spell out what is and what isn't the patient's responsibility. There's no blanket answer for this. Sometimes "disallowed" is provider discount, sometimes it's something not covered by the plan if done at the provider's office (but would be covered if done at the lab or whatever). If it's "disallowed" and put to patient at full price, chances are it's just not a covered benefit on the patient's plan and it's the patient's responsibilty to know that.

Answer 3

I'm not a biller but work at a clinic. I think often the clinic I work at resubmits it because sometimes they will reject it based on needing a treatment plan or the ss number is wrong or something else.

But if it really is denied then the patient will have some balance but it would probably be what the allowable amount is by the insurance company and not the full amount billed. And also the provider may reduce fee if it's denied .

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Answer 4

No. it doesn't become patient responsibility. Disallowed amount can refer to the provider's contractual discount, incidental procedures, duplicate charges, etc. The only amounts that should be billed to a patient are clearly listed as patient responsibility. Copays, coinsurance, deductibles, or services that are not covered by insurance(like cosmetic procedures)

Answer 5

EOB's usually have a part that lists patient responsibility - and obviously that's the part you have to pay.

If the "disallowed" amount is a fraction of the charge, then that means the provider (dr. office) has a negotiated price for that service with the insurance company - and the amount the provider CHARGED is greater than the negotiated price.  The patient is NOT responsible for the difference.  The provider will waive the rest of the fee.

If the disallowed amount is the entire charge - then most likely it was billed wrong and the provider will fix it without you having to do a thing.  If you get a bill from your Dr's office saying you owe that money (for the same thing that was on the disallowed column) - then call your insurance and find out why they refuse to pay it.

Answer 6

I agree with the above comments.  In addition appeal by calling the insurance company.  Frequently, the denial was a based upon a data error or something that can be retroactively corrected.  With many insurers there can be 2-3 levels of appeal.  Be polite but don't give up until you understand why it wasn't covered and why it can't be fixed.  Even then learn to use the system to avoid denial next time.

Answer 7

It depends on the reason disallowed.  Most EOBs will show two different columns: one for disallowed that are patient responsibility and one for contractual adjustments to the provider.  For example, if you had physical therapy and your doctor didn't get a referral for the service, the claim could be disallowed, but the doctor couldn't bill you (if the referral requirement was in his contract) ... this is usually true in an HMO.  But if you have a PPO plan that penalizes YOU for not getting a referral (or not using plan providers), you would be liable for part of the bill.

Call your insurance company if your EOB does not specifically state an "amount you owe".