Case Study 3- Explanation of Benefits and Payment Adjudication Henry, the billing supervisor that Gloria, the...

Case Study 3- Explanation of Benefits and Payment Adjudication

Henry, the billing supervisor that Gloria, the biller responsible for sending out patient statements, had charged several patients for the balance that insurance had not paid. In discussing with Gloria, Henry realized that she hadn’t been properly trained regarding balance billing. He explained that in most managed care plans, the difference between the amount billed and the amount allowed by insurance was to be entered as an adjustment and not billed to the patient.

Questions:

What should be done regarding the patients who were sent incorrect statements?

How could Henry have prevented this error from occurring?

Is balance billing allowed in non-managed care plans?

Solutions

Expert Solution

1. Clien'ts billing history and insurance coverage on limits need to be checked again. And proper correct statements need to sent again with apologies on inconvenience of incorrect statements.

2. By giving proper training ,having discussion and clarifing her doubts regarding the balance billing. Also proper verification of patients record. Precheck the bills before issued by biller. By this way Henry could have prevented this occurance of error.

3. Yes , balance billing is allowed for non managed care plans because mostly they are not in health insurance network coverage Plan

Nightingale answered 2 years ago

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