The Most Common Denials:
Patient Balance

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If you have a health plan and have a large copayment, deductible or other balance due to the medical provider, you should first confirm that the EOB (explanation of benefits) from your health plan shows that your claim was considered accurately.  Each time a health plan considers a claim, whether it is paid, partially paid, pended or denied, an EOB should be forwarded to both you and your physician about the action they took.

The following items will determine the amount of your personal out of pocket expense when a claim is submitted to the health plan:

  1. Are there differences in payment between participating and non-participating providers?
  2. Under what circumstances is a deductible or copay applied?
  3. What are the deductible and copay amounts?
  4. At what percentage will the health plan pay?

If the payment was accurate and you do have a balance owed to your physician or medical provider, then expect a statement explaining the amount you are responsible for.   When this is received, contact the business office to request consideration for a payment plan or prompt pay discount.  Remember, if you fail to make a payment or do not contact the provider to work out a payment arrangement, this bill could be sent to a bad debt agency and could have implications to your credit rating.