Open Icon Key

3rd Party Billing and Collections FAQ

3rd Party Billing and Collections FAQ

Q: When I get an Explanation of Benefits (EOB) from an insurance carrier, how do I know what to charge the patient and what must be written off?

A: If you are an In-network provider for the carrier, there will likely be an amount to write off for Provider Fee Schedule reductions. The patient may have a deductible, a co-pay, or a coinsurance depending on the patient’s specific policy provisions. For that reason, the EOB will have Remittance Advice Remark Codes which give you more details on each line item of the claim telling you how to process the payment and how to collect from the patient.

Q: When billing Medicare, I know we are supposed to pair up our diagnosis codes, which means there are two diagnosis codes for each region we are treating. This patient had treatment in three regions which means six codes are needed but there are only four spots for diagnosis codes. HELP!

A: It sounds like you are using an old claim form, which only has four spots for diagnosis codes. The new revised version of the CMS-1500 form has a spot for 12 diagnosis codes now, so you should have no problem communicating your patient’s codes to the carrier.

Q: When a patient comes in, how do we know what to collect? How do I make sure they have not already used their visits for the year?

A: One of the most important steps in the patient financial relationship is the verification of any insurance coverage held by the patient. The most accurate up-to-date information is usually obtained over the telephone so that you might ask detailed specific questions about the codes that might be billed or about certain benefit limits or visits already used.

Q: How do HSA's and flex plans work for maintenance care? I know patients can use them for Active chiropractic care but can they be used for maintenance/wellness care? Should we be billing them a certain way if it is considered maintenance?

A: HSA and HRA accounts are like savings accounts that can be used for any service medically related, like deductible, copayments, non-covered items, etc. The Internal Revenue Service has more detailed information on their website on exactly what services can be paid for out of an HSA account.

If the care is for Active Treatment, you would use the Chiropractic Manipulative Treatment codes (98940-98943). If the care is for maintenance or wellness purposes, the HCPCS code S8990 might be more appropriate.

Q: If an insurance company denies payment, then the bill becomes the patient's responsibility, right? But do we expect reimbursement from the patient in the amount of the actual fee or in the amount of the agreed upon rate that their insurance plan would have paid?

A: When an insurance companies denies a claim completely - not applying it to any deductibles or co-payments - the fee schedule for the carrier no longer applies. In most cases, you should then expect payment for your full fee from the patient. In some cases, depending on your individual provider contract, any services billed to the carrier that are determined to be not medically necessary are also not collectible from the patient unless you notified them in advance. We believe that when denial happens unexpectedly, it's a best practice to reach out to the carrier for an explanation. You should check your contracts to see which ones require that the Advance Notice of Non-Coverage be signed in order to collect. These are good reasons to fully verify coverage and to have copies of the carrier’s Medical Review Policies on file in your office.  

Q: When a patient has maxed out on their insurance benefits, do I keep submitting to insurance companies and just keep getting the denials, or should I sit down with the patient and switch them to cash?

A: Great question! Here are the steps in this process:

1. Always verify benefits on new patients or new cases.

2. Have a Financial Report of Findings (FROF) with the patients at the onset of care.

3. Touch base as you go to keep patients up to date on issues such as insurance not paying as expected or the patient falling behind in payments.

4. Enroll the patient in a DMPO such as ChiroHealthUSA so they can get discounted services (once their benefit has maxed, they may be underinsured).

5. Turn off billing when you encounter either non-covered services or maxed benefits so you can use address this with the patient.

6. Consider a service like Cash Practice for recurring payments to help patients create a budget for the necessary care.  


Q: I often threaten patients who have a balance with collections after they haven’t responded to a bill in several months. Sometimes I can’t even get them to call me back. I have never and am hesitant to actually send to collections however, and I’m not sure what's holding me back. Is all this OK?

A: This is a tough situation, because we really like our patients and usually develop a warm relationship with them. Put emotion aside and turn to your financial policies, acting based upon what's stated there. If you don’t have written policies in place, that’s probably why this is a stumbling block for you. You first have to decide if you're comfortable sending patients to collections when they don’t keep their end of what is truly a business arrangement: you provide care; they pay for services. Then, based on your decision, write a policy that clearly states how bad debt will be handled in your office and then stick to it. Above all, don't threaten collections unless you intend to go through with it. Important: make sure your compliance policy is clear about how you manage patient collections.

Q: What's the value of bundling each day's EOBs and saving/filing them by date? When would I reference this information? Is it just for record-keeping compliance?

A: The main reason that you want to know the date is in case you have to go back and reference that EOB later. You can correspond this date to the date the item was posted in your billing software, and then cross-reference it to any deposit slip that matches that date. Should anyone ever have to forensically follow the money, it makes a great paper trail. And trust us, there have been many times we've all had to go back to an EOB and pull it to see if it was entered correctly, or to do some follow-up after the fact. Some offices choose to copy all EOBs and put them into patient folder. This is so 1980s, and so not necessary these days because of the bulk checks that come in. Taking that full daily bundle and scanning it to make it an electronic copy just makes more sense. Bottom line: there's really no compliance issue, but it is definitely convenient.

Q: Are there different types of family/individual deductible arrangements? I thought that all eligible expenses went toward both the individual deductible and family deductible simultaneously until either one or the other was met and then benefits would be paid?

A: Not always. For example, someone might be the primary insured and have an HSA (Health Savings Account) with spouse and child as dependents. Even if the individual deductible has been met, benefits won't be paid until the family deductible has been met. So, effectively, the family deductible is the only relevant deductible.

Asking if there's a family deductible is one of the most important questions to ask when verifying insurance. You might want to say something like this: “I see that you have a family deductible. If an individual deductible is met by one, will that person now have benefits, or must the entire family deductible be met before anything is paid?” (Note: many people are confused by their own insurance. It's likely you'll have to call the relevant insurance party to be sure you're clear on this.)

Q: I have a patient that was involved in a car accident and who doesn't want me to bill her car insurance because she says her rates will go up. Don't I have to bill her car insurance before her medical insurance? Or does it not matter if she hasn't informed her car insurance company?

A: First, it depends on what state you live in. If you live in a “tort” state, where everyone has the option to purchase their own medical coverage (and assuming this is what your patient is talking about), then in most cases, using medical coverage, regardless of fault, will not affect rates. But that should be clarified with the insurance company.

Additionally, we recommend explaining to your patient that Box 10 of the Form CMS1500 asks the question, “Is Patient’s Condition Related to an Auto Accident?" By law, you have to check “Yes”, which means that the health insurance may not be liable and will more than likely not pay as the primary carrier - and if they do, they may subrogate any monies they pay out. If she is still unwilling and doesn’t want to file the auto insurance, she needs to pay at the time of service. To not say “Yes” on the CMS 1500 is in direct violation of the False Claims Act.

Q: After receiving patient compliants, I found my billing CA has processed several EOBs incorrectly. I looked further, and I'm afraid this may be a bigger problem than I thought. Is this cause for termination?

Let's start with a few questions:

  • Was your billing CA properly trained to do the job that is expected of her?
  • How was she trained; webinars, via your policy and procedures in your office compliance program, by the person leaving the position?
  • Did your billing CA sign off on the training so you know that she received it properly?

Ask yourself if you performed your job as the business owner properly by doing periodic audits or having your office manager provide you with the results of audits he/she is expected to perform of team members job duties.

What we're saying is that if the office has a broken system, our best recommendation is to get that fixed first, and then see how your billing CA performs with clear training and instruction. If she has received proper training and this is the first time she has been “audited,” it may simply deserve a conversation or a ‘write-up” with an allotted amount of time to improve. That is certainly your decision to make. Refer to your policy on proper handling of reimbursements. If you find that the office could use a tune-up to get your policies and compliance in place, give us a call!