Sunday, 15 October 2017

Allowed or Allowable

This is an amount established by an insurance company that it will pay for a health benefit. This varies per insurance company and per patient benefit contract. Some insurance companies may allow 100% of the submitted charges as the allowable amount. Some may establish their own internal amount. Medicare and Medicaid have their own established allowed amounts. Medicare pays 80% of its allowed amount if the patient has met their annual deductible. The patient pays the other 20% of the allowable. With Medicaid, it pays 100% of its allowable if the service is covered. Doctors or providers, when enrolling with Medicare and Medicaid agree to accept the allowed amount as payment in full. This means the patient cannot be billed for the difference between the provider’s charges and the Medicare/Medicaid allowed amounts. For example, a doctor may charge $160 for an office visit. The patient may have Medicare. Medicare may allow $60 for the visit. If the patient met their annual deductible, Medicare pays the doctor 80% of the $60 or $48. The patient pays the $12 difference between the $60 allowed amount and the $48 payment. The doctor cannot charge the patient the difference between the $160 charge and the $60 allowed amount. The provider must perform an adjustment between the $160 charge and $60 allowed amount. The patient can only be billed for their 20% of the allowable and any amounts applied to their deductible. With commercial insurance, if the doctor is non-par or not contracted with the patient’s health insurance company, the doctor doesn’t have to accept the allowed amount or paid amount as payment in full. The provider can bill the patient the difference between the charges and payment. This may not be so with HMOs in a state with a no-balance billing HMO law.

Ancillary Services: 
Medical care, other than those provided by the physician or hospital, which are related to a patient’s care. Examples are laboratory work, x-rays, physical therapy, and anesthesia 

ATD (Applied to Deductible)
The portion of the claim that the patient is required to meet before the insurance company pays the claim. The claim may have been $100. The insurance company allows $100. The patient has a $100 deductible they haven’t met. The EOB is received without payment with the $100 ATD (Applied to the deductible). You would change the account responsibility to self Pay and bill the patient the $100 that is owed.

Monday, 9 October 2017

Accord and Satisfaction

An accord and satisfaction is a legal term we face when an insurance company or patient writes “paid in full” on the check which is also known as an instrument. Some people do this in the belief that if they do this, they no longer owe anything on their debt. An accord is an offer to settle the debt for an amount that is less than what is owed. A satisfaction is an agreement to the accord. Some states have laws that regulate an accord and satisfaction. For example, under Florida Law, the law states the following:

673.3111 Accord and satisfaction by use of instrument.--

(1) If a person against whom a claim is asserted proves that that person in good faith tendered an instrument to the claimant as full satisfaction of the claim, that the amount of the claim was unliquidated or subject to a bona fide dispute, and that the claimant obtained payment of the instrument, the following subsections apply.

 (2) Unless subsection (3) applies, the claim is discharged if the person against whom the claim is asserted proves that the instrument or an accompanying written communication contained a conspicuous statement to the effect that the instrument was tendered as full satisfaction of the claim. 

(3) Subject to subsection (4), a claim is not discharged under subsection (2) if either paragraph (a) or paragraph (b) applies: 

(a) The claimant, if an organization, proves that: 

1. Within a reasonable time before the tender, the claimant sent a conspicuous statement to the person against whom the claim is asserted that communications concerning disputed debts, including an instrument tendered as full satisfaction of a debt, are to be sent to a designated person, office, or place; and 

Tuesday, 3 October 2017

ABN (Advanced Beneficiary Notice)

In Medical Billing, we have our own language. Things such as EOBs, PPOs, HMOs, POSs, Catastrophic Cap, Deductibles and more can be very frightening if not understood. During training, medical coders and medical billers learn medical terminology. Medical Billing terminology is going to the next step to learn language medical billers face every day when interacting with patients, health benefits, and claims. There is a huge difference between otitis media and coordination of benefits (COB). Otitis Media is medical terminology. It is also a diagnosis that is converted by a coder from words to numbers that are recognized by an insurance company. COB is medical billing terminology, used by medical billers when interacting with multiple insurance policies carried by a patient. 

An ABN is a written notice from Medicare (standard government form CMS-R- 131), given to you before receiving certain items or services, notifying the patient:

• Medicare may deny payment for that specific procedure or treatment. 
• The patient will be personally responsible for full payment if Medicare denies payment.

An ABN gives the patient the opportunity to accept or refuse the items or services and protects the patient from unexpected financial liability in cases where Medicare denies payment. It also offers the patient the right to appeal Medicare's decision. You follow office policy on keeping the ABN form on file and you ad the modifier GA to the claim. Modifier GA informs Medicare of the ABN transaction. If you do not have the patient sign the ABN form and the claim is denied, then you cannot bill the patient for the denied claim.

The patient has the option to receive the items or services or to refuse them. In either case, the patient should choose one option on the form by checking the box provided, and then signing and dating it in the space provided.

When the patient signs an ABN and becomes liable for payment, the patient will have to pay for the item or service themselves, either out-of-pocket or by some other insurance coverage which they may have in addition to Medicare. Medicare fee schedule amounts and balance billing limits do not apply. The amount of the bill is a matter between the patient and provider. If this is a concern for the patient, they might want to ask for a cost estimate before they sign the ABN.

Thursday, 28 September 2017



TNF inhibitors, including REMICADE®, have been associated in rare cases with CNS manifestation of systemic vasculitis, seizure, and new onset or exacerbation of CNS demyelinating disorders, including multiple sclerosis and optic neuritis, and peripheral demyelinating disorders, including Guillain-BarrĂ© syndrome. Exercise caution when considering REMICADE® in patients with these disorders and consider discontinuation if these disorders develop.

Treatment with REMICADE® may result in the formation of autoantibodies and, rarely, in development of a lupus-like syndrome. Discontinue treatment if symptoms of a lupus-like syndrome develop.

In clinical trials, the most common REMICADE® adverse reactions occurring in >10% of patients included infections (eg, upper respiratory, sinusitis, and pharyngitis), infusionrelated reactions, headache, and abdominal pain.

Concomitant use of REMICADE® with anakinra, abatacept, tocilizumab, or other biologics used to treat the same conditions as REMICADE® is not recommended because of the possibility of an increased risk of infection. Care should be taken when switching from one biologic to another, since overlapping biological activity may further increase the risk of infection.

Live vaccines or therapeutic infectious agents should not be given with REMICADE® due to the possibility of clinical infections, including disseminated infections. 

Bring pediatric patients up to date with all vaccinations prior to initiating REMICADE®. At least a 6-month waiting period following birth is recommended before the administration of any live vaccine to infants exposed in utero to REMICADE®

Saturday, 23 September 2017


TNF inhibitors, including REMICADE®, have been associated with reactivation of hepatitis B virus (HBV) in patients who are chronic carriers. Some cases were fatal. Patients should be tested for HBV infection before initiating REMICADE®. For patients who test positive, consult a physician with expertise in the treatment of hepatitis B. Exercise caution when prescribing REMICADE® for patients identified as carriers of HBV and monitor closely for active HBV infection during and following termination of therapy with REMICADE®. Discontinue REMICADE® in patients who develop HBV reactivation and initiate antiviral therapy with appropriate supportive treatment. Exercise caution when considering resumption of REMICADE® and monitor patients closely.


Severe hepatic reactions, including acute liver failure, jaundice, hepatitis, and cholestasis have been reported rarely in patients receiving REMICADE® postmarketing. Some cases were fatal or required liver transplant. Aminotransferase elevations were not noted prior to discovery of liver injury in many cases. Patients with symptoms or signs of liver dysfunction should be evaluated for evidence of liver injury. If jaundice and/or marked liver enzyme elevations (eg, ≥5 times the upper limit of normal) develop, REMICADE® should be discontinued, and a thorough investigation of the abnormality should be undertaken.

Cases of leukopenia, neutropenia, thrombocytopenia, and pancytopenia (some fatal) have been reported. The causal relationship to REMICADE® therapy remains unclear. Exercise caution in patients who have ongoing or a history of significant hematologic abnormalities. Advise patients to seek immediate medical attention if they develop signs and symptoms of blood dyscrasias or infection. Consider discontinuation of REMICADE® in patients who develop significant hematologic abnormalities.

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