Medicare Compliance & Reimbursement - 2013 Issue 4
Reader Question: Avoid Skirting the System to Save Patients Money
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Article Overview
This reader Q&A explains how a medical practice should think about billing when a patient asks to pay expected allowed charges directly instead of the deductible amount. It focuses on contract-based billing workflow, the role of the explanation of benefits, and how participation status affects fee collection. The article is relevant to office managers, billers, coders, and compliance-focused practice staff who handle payer contracts and patient balances.
Why This Topic Matters
Improper handling of claims and patient payments can create compliance risk, payment disputes, and contract problems with the payer. Understanding the billing process described in the article helps practices avoid errors when patients have high deductibles or ask for alternative payment arrangements.
What You Will Learn
- How payer contracts affect claim submission and patient collection
- Why the explanation of benefits matters in determining patient responsibility
- How deductible and allowable-charge questions are handled in a contracted versus non-participating setting
- What compliance risks can arise when claims are not submitted
Who Should Read This
- Medical office managers
- Billing staff
- Professional coders
- Practice compliance staff
- Physician practices
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