Home
About Us
Welcome Video
Company Overview
Our Purpose
A Message from our CEO
Giving Back
Locations
Testimonials
Leadership
Executive Team
Legal Team
Careers
Contact
Phia Certification
Diversity & Inclusion
Privacy Statement
Technology
Services
Learn - Independent Consultation & Evaluation
Plan - Phia Document Management
Plan - Plan Drafting Services
Save - Claims, Recovery & Subrogation Services
Save - Claim Negotiation
Save - Phia Unwrapped
Protect - Plan Appointed Claim Evaluator (PACE)
Protect - Balance Billing Resolution
Phia International
Media
Webinars
Newsletters
Publications
Blog
Press Releases
Podcasts
Industry Articles
Guide to Understanding Subrogation
Moving To Self-Funded Health Plan Guide
Referenced-Based Pricing Explained
Hospital Price Transparency Guide
Balance-Billing: What Patients Need To Know
Employee Rights With COVID-19 Vaccines
The No Surprises Act Explained
Mental Health Parity and Addiction Equity Act Explained
Understanding Non-Quantitative Treatment Limitations (NQTLs)
The Insulin Cap Bill Offers Hope for Americans With Diabetes
Industry Terms
Members Area
FAQs
FAQ - Subrogation & Reimbursement
FAQ - Mass Tort Subrogation & Reimbursement
Questionnaire Response
Make A Payment
|
Login
GO
X
Home
About Us
Welcome Video
Company Overview
Our Purpose
A Message from our CEO
Giving Back
Locations
Testimonials
Leadership
Executive Team
Legal Team
Careers
Contact
Phia Certification
Diversity & Inclusion
Privacy Statement
Technology
Services
Learn - Independent Consultation & Evaluation
Plan - Phia Document Management
Plan - Plan Drafting Services
Save - Claims, Recovery & Subrogation Services
Save - Claim Negotiation
Save - Phia Unwrapped
Protect - Plan Appointed Claim Evaluator (PACE)
Protect - Balance Billing Resolution
Phia International
Media
Webinars
Newsletters
Publications
Blog
Press Releases
Podcasts
Industry Articles
Guide to Understanding Subrogation
Moving To Self-Funded Health Plan Guide
Referenced-Based Pricing Explained
Hospital Price Transparency Guide
Balance-Billing: What Patients Need To Know
Employee Rights With COVID-19 Vaccines
The No Surprises Act Explained
Mental Health Parity and Addiction Equity Act Explained
Understanding Non-Quantitative Treatment Limitations (NQTLs)
The Insulin Cap Bill Offers Hope for Americans With Diabetes
Industry Terms
Members Area
FAQs
FAQ - Subrogation & Reimbursement
FAQ - Mass Tort Subrogation & Reimbursement
Questionnaire Response
Make A Payment
Home
+
About Us
Welcome Video
+
Company Overview
Our Purpose
A Message from our CEO
Giving Back
Locations
Testimonials
+
Leadership
Executive Team
Legal Team
Careers
Contact
Phia Certification
Diversity & Inclusion
Privacy Statement
Technology
+
Services
Learn - Independent Consultation & Evaluation
Plan - Phia Document Management
Plan - Plan Drafting Services
Save - Claims, Recovery & Subrogation Services
Save - Claim Negotiation
Save - Phia Unwrapped
Protect - Plan Appointed Claim Evaluator (PACE)
Protect - Balance Billing Resolution
Phia International
-
Media
Webinars
Newsletters
Publications
Blog
Press Releases
Podcasts
+
Industry Articles
Guide to Understanding Subrogation
Moving To Self-Funded Health Plan Guide
Referenced-Based Pricing Explained
Hospital Price Transparency Guide
Balance-Billing: What Patients Need To Know
Employee Rights With COVID-19 Vaccines
The No Surprises Act Explained
Mental Health Parity and Addiction Equity Act Explained
Understanding Non-Quantitative Treatment Limitations (NQTLs)
The Insulin Cap Bill Offers Hope for Americans With Diabetes
Industry Terms
+
Members Area
+
FAQs
FAQ - Subrogation & Reimbursement
FAQ - Mass Tort Subrogation & Reimbursement
Questionnaire Response
Make A Payment
Posts
Media
>
Posts
Webinars
Newsletters
Publications
Blog
Press Releases
Podcasts
Industry Articles
Guide to Understanding Subrogation
Moving To Self-Funded Health Plan Guide
Referenced-Based Pricing Explained
Hospital Price Transparency Guide
Balance-Billing: What Patients Need To Know
Employee Rights With COVID-19 Vaccines
The No Surprises Act Explained
Mental Health Parity and Addiction Equity Act Explained
Understanding Non-Quantitative Treatment Limitations (NQTLs)
The Insulin Cap Bill Offers Hope for Americans With Diabetes
Industry Terms
Phia Group
Phia Group Media
Full Billed Charges: A Question of Geography
On June 21, 2017 in
Balance Billing
,
Blog
,
Cost Containment
,
Healthcare Costs
,
Self Funding
By: Jon Jablon, Esq.
It is increasingly common within the self-funded industry for medical providers to demand full billed charges for non-contracted claims. As we know, no one is actually required to pay full billed charges – but when push comes to shove, that tends to be the prevailing demand.
What about when the plan document limits payment at a percentage of Medicare? Say, 150%? The fiduciary has a duty to strictly abide by the terms of the plan document when making payments – and the definition of a non-contracted claim is that there is no contract to provide services at an agreed-upon price. Interestingly, though, and perhaps rendering it a misnomer, a non-contracted claim is still subject to two distinct contracts – an assignment of benefits, and the all-important plan document.
The plan document, of course, defines the Plan’s payment mechanisms and explains beneficiaries’ rights. When the plan document says that the Plan will pay $X, and the Plan does pay $X, the Plan has followed the terms of the plan document to a T. Or to an X, anyway. Let’s boil that down as simply as possible: X = X. What could be simpler than that?
Next, the assignment of benefits is an agreement between the patient and the provider. The patient says “I will transfer you all health plan benefits due to me ($X), and I promise that if $X does not compensate you fully, I will pay whatever balance you think makes sense.” In return, the medical provider promises to provide valuable medical services. We at The Phia Group have discussed the concept of assignments of benefits ad nauseum, and for good reason; this is the mechanism by which medical providers become beneficiaries of Plan benefits, and are due $X from the Plan.
Question: does an assignment of benefits give providers the right to receive full billed charges from the Plan, even though the Plan limits its benefits to an amount less than billed charges? There are a lot of moving parts in the self-funded industry, and this is yet another; the answer you may not have expected is maybe: it depends on the Plan’s geography.
Is the Plan domiciled in Fantasyland, home of laughable arguments, unexplainable oddities, and absurd logic? Then yes – billed charges will be due on every non-contracted claim, regardless of plan document language.
Or, is the Plan domiciled in Realityville, where general legal and market principles do exist, words have actual meaning, and hospitals and attorneys can be expected to be at least reasonably informed? If that’s where the Plan is, then no – of course an assignment of benefits doesn’t guarantee payment of full billed charges.
What are you, nuts?
Tagged With:
Balance Billing