Wow! This was a Godsend. I am taking my exam in one hour. I have been in a billing/coding course for a year. Calculating patient responsibility did not make sense this whole time... until I watched your video. I wish I found you sooner. Would have taken your zoom course. Thank you immensely! I wish I could hug you :)
@@AskTheBiller yay! 😊 I’m starting a new career path and your expertise is perfect for my learning style. After finding this vid and seeing the synchronicity of dates, it’s all the confirmation I need that I’m headed in the right direction. I’m so glad I found you! Thank you for your dedication to lead a community!
@@kgee1576 Thank you so much! I appreciate your kind words. I love newbies! This is such an amazing and rewarding industry. There's a lot to learn, and I hope to help make the concepts simple and easy to understand, because it doesn't have to be complicated. Stay tuned for new content.😊
This is so helpful. I understand it way better this way. I went to school for medical office and billing specialist last, completed the course but do work in the field because I didn’t quite understand what I was doing but you have explained this wonderfully. I now have confidence to take the exam and get off into the field. Really wish there was some out there that could explain coding like this.
Thank you so much, Sabrina! I can refer you to great coding instructors. Feel free to email me at askthebiller@gmail.com. Best of luck with your exam : )
Hello my name is Jacqueline Denise Bethea I am in school now doing Medical Billing and Coding online I am very interested in doing your group I like the way how you break everything down so I can understand better so tell me how can I join the group thank you again, Jacqueline Bethea.
Thank you SO MUCH for this! I’m taking my NHA CBCS certification exam tomorrow and I am just refreshing my knowledge of patient responsibility. You make it clearer than the entire program I took. I will probably join you on Wednesday nights to learn more about the billing aspect…I have coding down but billing is still tricky for me. So happy I found you!
Thank you so much. I was so confused with all of this before you. The book we are using is very vague in describing how to calculate. You are an angel.
I'm going to school for medical records specialist but I'm having a very hard time doing deductibles and co-pays and all of that adding them just like you showing your video which was very helpful do you have more examples and more of a breakdown on how to do that
thank you thank you thank you! I'm currently taking an online medical billing/coder class and I was super lost! I can tell you love what you do and this gives me inspiration to keep going and not give up on this class.
I am so glad that people like you are able to make videos helping out students, this really helped me understand most of the medical billing part of the Health Insurance and Medical Billing tests in BPA. Hopefully my results improve for state BPA.
Oooh my god the way u taught really helped me a lot .without doing this problem i failed in my assessment from training so i lost my job . And now i got selected in another company i am very much confident to crack the assessment ...... I never forget yours help thankyou so much.
This video is worth a million lol 😂 I love how you did this, I just started a new billing job and I have to explain bills and eobs to patients. This is perfect. Thanks so much you are awesome and I hope to take your course once I finish my CPC certification. Thanks so much 😊
@@IamShanRich Thank you so much for your kind words. Educators need encouragement too and your feedback made my day.😊 I appreciate you and look forward to assisting you learn medical billing. Best of luck with your CPC course and exam.❤️
Oh my gosh I love you!!!!!!!! I finally get it now I am taking my medical and billing coding exam for the 2nd time on friday You are so so helpful I will be watching you videos..
Thank you so much; this video is exactly what I needed...I’ve scheduled a consultation with you later this month to get additional help in this area...you’re videos are very helpful, Thanks again 👏🏾👍🏾😌
Girlfriend you are heaven sent. I have been trying to get a breakdown for a while and you gave me everything I needed and then some. I need more help so I will be tuning in whenever I can. Do you still have the online breakdowns going?
@@mdowling835 Thank you 🫶🏾 I’m so glad to know the video was helpful. I am long overdue for creating more breakdowns but I have some posted on instagram.com/askthebiller
@@AskTheBiller thanks but I do not have instagram only youtube and facebook. I hope I will be able to find your updates on either one of these. I don't do well with social media so these two are fine for me.
Can you enlighten me with this one? This is an example from our training. Heres the only information provided including the questions. Thank you so much in advance. Scenario: Mark has an insurance policy with 100 Usd monthly premium , a 1000 USD deductible and a 5000 USD out of pocket maxim. He broked his leg and got a hospital bill of 10000 usd , how much of this bill he has to pay? How much is total expenses of mark considering his deductibles and out of pocket? How much of total expenses will be covered by the insurer?
Hi. This is not enough information. In order to calculate his responsibility, I would need to know the allowed amount on the claim and how much of his deductible and out of pocket max has been met.
Hi Quiana! I really love how you explain each terms and gave different examples for each scenarios. May I kindly ask what is the adjustment for? and for example number 1, what the total amount of the patient is responsible to pay? is it 80? since copay is not covered by the insurance plus the 40 patient responsibility? Thank so much in advance as this would help me to become an effective HR and I am new with the US health insurance.
Hi Quiana. I am really new to insurance and medical billing. In your example 4, why is that the patient responsibility is 0USD and what does remainder of their benefit year means? And does the adjustment is the amount the patient is going to pay? Thanks a lot and it will be a big help for me.
The patient responsibility is $0 because their "out of pocket maximum" has been reached. Once that amount has been reached the insurance will cover 100% of the allowed amount. Their benefit year can run on a "calendar" year, Jan 1 to Dec 31, or a "plan" year which may start on any other day of the year. This is the time period for when their benefits are eligible. Their benefits could possibly change or terminate at the end of the benefit year. The adjustment (or the amount written off) is the amount not covered. The adjustment is not the patient's responsibility if the provider is in network and participates with the plan.
Me too, thank you!❤ The insurance is going to subtract unmet deductible when calculating their reimbursement. It gets applied to patient responsibility so that amount has to be added back in along with the coinsurance. Make sense?
Unmet out of pocket maximum is very common. That just simply means the patient continues to pay their copay, coinsurance and/or deductible. Once the out of pocket maximum has been met, the patient will no longer have out of pocket costs until their next plan year. So if they meet their out of pocket maximum on June 1st and their plan renews on January 1st from June 1st through December 31st the patient would not pay anything since the insurance will pay 100% of the allowed charges. Hope this helps!
I just finished my Administrative Medical Assistant course and i learn about medical billing and coding, you explained it very easy. Can you please provide me with the zoom information about yure class.
Thank you for your video! I watched lots of videos about this topic and you clearly explained everything. You're examples helped me a lot. Thanks again!
This is a great video It just leaves one question what happens to the adjustment amount? Does the patient has to pay this as I assume it was billed to the patient and the insurance reimburses only the % of the allowed amount? Thank you for your advice
If patient has a deductible and also a coinsurance, they’re deductible has to first be met before the coinsurance metric kicks in correct? - love your videos btw
Good morning,I was interested in joining your on-line refresher insurance class. I have been in the medical field for many years and have recently changed positions . In my new position I will be required to verify patients' benefits and what their cost will be for services. I found your video extremely helpful. You mentioned you have a 6 week refresher course held every Wednesday. I am interested if you still offer this class.Thank you for your time Nancy Etter
@@NancyEtter-y7t Good Morning Nancy. Yes, I still offer the training course with included live weekly Q&A classes. Please send an email to askthebiller@gmail.com for further details. Thank you!
Only 10 comments for this very precious video...... I think still people don't know about medical billing or i think 90% of people..... They became owners of individual medical billing company 😁🤣
Very informative video ma'm you reminded me the stuff i forgot........ It's been a long time to left medical billing..... On monday I'm gonna face HR for medical biller....
I'm working in a billing company with AR professionals and I am enjoying a lot...... Thanks to ALMIGHTY and your videos are very helpful thanks a lot 😇👍
How can you tell if there is a contractual adjustment? All the fields that the EOB I'm looking at provides is: Fee charged, PDP (if applicable), covered expense, benefit paid. If there is something in the PDP fee column does that indicate a contractual adjustment?
Some of the insurance payer EOBs are more thorough than others. The best thing to do is to contact the payer and have them confirm the contractual adjustment amount. It may be on their portal/website or you can call provider services and speak with a live representative. Hope this helps!
How would you calculate example 5 if they had not yet hit their out of pocket maximum but the patient responsibility of $4588 would put them over their out of pocket maximum?
Hi Shandy. The patient would only be responsible for the amount up to the out of pocket maximum. The EOB will show the amount up to their OOP max and then the insurance would pay the excess amount. Once their OOP maximum is reached the insurance will pay 100% of the "allowed" amount until their benefit year ends.
I’m glad to hear that!😊 An in network provider accepts the total “allowed” amount as reimbursement in full. So the adjustment, which is the difference between what was billed and what was allowed, is written off of the patient’s account.
Loved your video! I just have a few questions about medical billing: firstly, is it possible to get into medical billing in a behind-the-scenes role? I'm interested in the field but would prefer a role that's not front desk. Also, do employers train you in understanding the insurance guidelines?
Thank you! When you say "behind the scenes role" what exactly do you mean? Not having direct contact with patients? That is possible. It depends on the scope of work you are hired for. You may not have to handle any patient inquiries and solely focus on working the claims. Most medical billers do not receive formal training and learn as they go. You can go to the insurance payers websites and see what resources they have available.
@@codewithsharen1404 They don’t have to learn everything a biller should know, however, I think business owners should understand the basics of the health plan they purchase for employees. If they don’t understand the benefits, they should have an HR professional or insurance broker accessible to explain the plan to employees.
So i am reading over my CPC study guide. I don’t understand the RBRVS, work RVU scale thing. Is knowing how to calculate facility or non facility pricing amounts more of a coding thing or billing thing?
How do you get the allowed amount please and thank you? I'm taking a class and I'm so confused. Your video did help much more than my instructor 🤦🏽♀️🙏🏼
Hi Crissy. The allowed amount is determined by the insurance payer. If the provider is in network (they have signed a contract/agreement with the insurance) the allowed amount is predetermined and can be disclosed by provider services. The provider should have access to the fee schedule with the CPT/HCPCS codes and the allowed amounts. Unfortunately, I hear this frequently. A lot of students are not satisfied with their instructors. But I am happy to be a resource! Take care.
In your example 5, Is it possible that the remaining unmet deductibles are gradually deducted from the patients instead of full amount on the treatment from the patient.
This really clarified things for me (I'm an NP.) Let's say a patient's primary insurance is Medicare bur they have a secondary insurance, e.g., a Medicare supplement plan. I am an in-network Medicare provider but not in-network for their supplement. Do I do the calculations described in the video using Medicare numbers? Will you eventually do a video about not in-network provider calculations? Thanks so much! Very best, Abby Stuthers, NP
If a patient has a $1750 deductible with primary insurance. Our allowable is $1250. None of the Deductible has been met. They also have a secondary insurance that just happens to be Medicare. Our allowed amount with them is $1108.54. How do I figure out how much the patient will owe?
Hello. I am currently in the Medical Billing part of my online Medical Coding Course. Learning who pays first when multiple agencies invilved. Trying to understand why all don't charge the same and pay the same...
Do any of the out of pocket expenses accumulate towards the deductible? For example, if a person goes to the doctors office and pays co-pays or coinsurance throughout the year. Do those out of pocket costs go towards the deductible (until it's met) and then taken out of the total out of pocket maximum- until thats met?
Hi Markuz. It depends on the plan. Some plans will apply all out of pocket expenses (copays, coinsurance and deductible) to the "out of pocket maximum". But copays and coinsurance do not get applied towards deductible. That is a separate out of pocket expense that accumulates on its own.
So example 3 the adjustment is $260 this giving be written off? Because the patient is only responsible for paying the $330 allowed amount due to not met their ded?
That was really helpful. My job, which is adjustment, is for a hospital. I'm being trained by someone who isn't very helpful. Since he has been employed by the company for more than 8 years, he is qualified to examine the account and determine where adjustments are required. Contrary to me, who comes from a nursing home and handles private billing, this is completely foreign to me. I'm not sure whether you can help with this, but if you can, that would be really appreciated.
2 yrs later. .the last example...if pt has unmet deductible amount and 60/40 we ALWAYS subrtact unmet ded from allowed amount...then multiply it by 40% then 60%? Is that ALWAYS THE WAY ?
Hello, I am still confused about how to calculate the write off amount. Is there a specific formula that I need to use to calculate or determine it. In what ways there is no write off amount?
Yes, for in network claims the formula to calculate the write off amount is “the allowed amount aka the contracted rate - the paid amount = the adjustment aka the write off amount.
Thank you for explanation, a QUESTION. Does your deductible meet by service date or by claim date? I have Aetna, and could not find any info (standard saving)
Deductibles accumulate according to the date the claim was processed. For example, if you submit a claim with DOS 1/15/24 that processes on 1/30/24 and applies to deductible it’s possible that a claim with DOS 1/2/24 submitted in March processes and pays because deductible was met when the claim was received. Does that make sense?
@@AskTheBiller yes, first come-first serve. How about DOS from last yest 12/23/23 and claim was done 1/4/2024, does the same principal apply? Will that cost go towards this year deductible since claim was received this year. When i called insurance they said they go by CLAIM DATE, not the date of service, yet refusing to apply this clam towards deductible for this year.
Hi can you explain how the Billed amount is calculated and what you mean by the amount that is “written off” is there any tax ramifications or is it just a “discount” for the services being in network?
The billed amount is determined by the provider. They can use resources like fairhealth.org to create their internal fee schedules for their services. The write off/adjustment amount is a discount for being an in network/participating provider. There are no tax ramifications.
My medical billing course is pre recorded and self paced. In addition, we meet live weekly via zoom for Q&A. Please visit my website www.JustAskTheBiller.com for details or email me at askthebiller@gmail.com. Thank you!
Hi I'm new to your channel and I love your videos. Thank you so much for making such informative videos. Was just wondering what happens to adjustments? Is the amount the provider is willing to let go? Or should this be including for ptx oops? Thank u in advance. More power!
Hi Jane. Thanks so much for watching and for the positive feedback! When a provider signs a contract and is in network/participating with a plan, they have agreed to accept specific rates for each CPT/HCPCS code as payment in full. So the adjustment is let go as you stated because the amount in excess of the contracted rate has to be written off of the patient's account. Hope this answers your question. Take care!
Hi, my question is: If the patient has a primary and secondary Insurance. The primary deductible is 1,000 and has not met. Do you bill the secondary Ins. Prior to collecting the primary deductible? Ty in advance your video was excellent! Clare
How do you calculate the patient out of pocket amount when there is a secondary insurance? In this case Medicare is primary and the secondary has a 10% coinsurance. You’re the best!
Hi Anna. Thanks so much : ) It depends! If Medicare applies the charges allowed to the patient's deductible, the secondary insurance may or may not pay. Some secondary plans do not cover deductible. But if Medicare does make a payment, the remaining 20% is what the secondary insurance would consider and then the patient may be responsible for 10% of that remaining balance. It's hard to say! I would just explain the benefits as far as deductible and coinsurance. I don't think I would specify a dollar amount in this case.
I have a question pertaining to how the provider is payed. If a patient has a large deductible, does the reimbursement go to the provider or is it the patients responsibility to pay the provider. We have cases where the patients deductible was payed down and the provider received nothing.
Hi. When the allowed amount is applied to deductible and the insurance pays $0, you have to bill the patient. The patient has to pay the amount applied to patient responsibility.
Submit the claim to the primary insurance. When you receive the primary EOB, submit it with the secondary claim and see if they pay the primary copay. If not, bill the patient.
I am a registration clinic. I understand the copay part but when it comes to what the patient owes before they see the doctor with a deductible that's either met or not bet how do you figure their cost
Hi Michaelene. If the provider is "in network" and participates with the patient's plan, they have signed a contract with the insurance company and agreed to specific rates for each service. If the patient is coming in for a follow up visit you would look up the code on the fee schedule to confirm the "allowed" amount. If the patient's deductible has not been met and it exceeds the allowed amount you can charge the patient the allowed amount upfront. So for example, the patient has a $1000 deductible, $100 has been met and they are coming in for a follow up visit. The CPT is 99213 and the allowed amount is $150. You can collect $150 upfront at the time of service and submit the claim. After the claim processes confirm on the EOB (explanation of benefits) that the allowed amount and the amount applied to the deductible matches what you charged the patient. If more was applied to the deductible you would balance bill the patient the difference that they owe. If less was applied to the deductible you would refund the excess amount collected to the patient. And if a payment was made by the insurance payer and nothing was applied to deductible you would refund the patient $150. Hope this helps!
Hello good evening I did Medical Billing years ago and would like a refresher course as I started a new job that includes medical Billing. How can I be a part of your class
Hi Antonia. My refresher course covers the fundamentals of the entire revenue cycle. Here is the link and you can enroll anytime. Thank you! askthebiller.myshopify.com/products/1621013
Referreing to Example #5: Is the "Provider" able to keep the unmet deductible plus what was covered by the insurance? So the total income received is $5866. Did I get that correct? Thank you so much .
You are doing the lord’s work, this is the first time it had made sense, big THANK YOU!!! ❤
😂 I’m so glad to hear that! Thanks for watching.❤️
Wow! This was a Godsend. I am taking my exam in one hour. I have been in a billing/coding course for a year. Calculating patient responsibility did not make sense this whole time... until I watched your video. I wish I found you sooner. Would have taken your zoom course. Thank you immensely! I wish I could hug you :)
Thank you so much ❤ Good luck on your exam!!!
Thank you!
The fact that I’m watching this Aug 13th, ‘24 and slide #5 is dated Aug 13, 2021… mad wild! 😮
@@kgee1576 happy video anniversary 🤷🏾♀️😂👋🏾
@@AskTheBiller yay! 😊 I’m starting a new career path and your expertise is perfect for my learning style. After finding this vid and seeing the synchronicity of dates, it’s all the confirmation I need that I’m headed in the right direction. I’m so glad I found you! Thank you for your dedication to lead a community!
@@kgee1576 Thank you so much! I appreciate your kind words. I love newbies! This is such an amazing and rewarding industry. There's a lot to learn, and I hope to help make the concepts simple and easy to understand, because it doesn't have to be complicated. Stay tuned for new content.😊
This is so helpful. I understand it way better this way. I went to school for medical office and billing specialist last, completed the course but do work in the field because I didn’t quite understand what I was doing but you have explained this wonderfully. I now have confidence to take the exam and get off into the field. Really wish there was some out there that could explain coding like this.
Thank you so much, Sabrina! I can refer you to great coding instructors. Feel free to email me at askthebiller@gmail.com. Best of luck with your exam : )
Hello my name is Jacqueline Denise Bethea I am in school now doing Medical Billing and Coding online I am very interested in doing your group I like the way how you break everything down so I can understand better so tell me how can I join the group thank you again, Jacqueline Bethea.
@@babybearbethea7310 please visit www.JustAskTheBiller.com to enroll.😊
Thank you SO MUCH for this! I’m taking my NHA CBCS certification exam tomorrow and I am just refreshing my knowledge of patient responsibility. You make it clearer than the entire program I took. I will probably join you on Wednesday nights to learn more about the billing aspect…I have coding down but billing is still tricky for me. So happy I found you!
You’re very welcome! Medical billing doesn’t have to be complicated. Wishing you all the best on your exam tomorrow!!!❤️
All I can say is thank you for breaking this down for me. You were extremely helpful.
You’re welcome!!!🫶🏾
You are amazing! I made up my own numbers and followed your guide for ea example. I'll need to know how to calculate for my job. God bless you ❤️❤️
I'm so glad this was helpful! Thanks for watching.☺
Thank you so much. I was so confused with all of this before you. The book we are using is very vague in describing how to calculate. You are an angel.
You're very welcome, Stacey. So glad this video gave you clarity : )
Thank you life saver! I understand it way better now!
So happy to hear that!!🙂
Just came across your channel today. You are a good teacher. I will be watching more of your videos.
Thank you so much! I appreciate that.♥
I'm going to school for medical records specialist but I'm having a very hard time doing deductibles and co-pays and all of that adding them just like you showing your video which was very helpful do you have more examples and more of a breakdown on how to do that
This is the only tutorial I have on medical billing calculations but stay tuned for new content!
Your breakdown of the billing process was so helpful, thank you!
You’re very welcome! Thanks for watching ❤️
thank you thank you thank you! I'm currently taking an online medical billing/coder class and I was super lost! I can tell you love what you do and this gives me inspiration to keep going and not give up on this class.
Thank you so much! NEVER give up. There are resources out here to assist you along your medical billing journey.
Thank you very much for a very informative and easy-to-understand computation for patient and payer responsibility.
@@eubheabenio7357 you’re welcome 😁
I am so glad that people like you are able to make videos helping out students, this really helped me understand most of the medical billing part of the Health Insurance and Medical Billing tests in BPA. Hopefully my results improve for state BPA.
I’m so glad you found this helpful.😊
Oooh my god the way u taught really helped me a lot .without doing this problem i failed in my assessment from training so i lost my job . And now i got selected in another company i am very much confident to crack the assessment ...... I never forget yours help thankyou so much.
You’re welcome!! Good luck. Let me know if you get the job.🙏🏾😁
thank you for this break down
You're welcome!🙂
This video is worth a million lol 😂 I love how you did this, I just started a new billing job and I have to explain bills and eobs to patients. This is perfect. Thanks so much you are awesome and I hope to take your course once I finish my CPC certification. Thanks so much 😊
@@IamShanRich Thank you so much for your kind words. Educators need encouragement too and your feedback made my day.😊 I appreciate you and look forward to assisting you learn medical billing. Best of luck with your CPC course and exam.❤️
Oh my gosh I love you!!!!!!!! I finally get it now I am taking my medical and billing coding exam for the 2nd time on friday You are so so helpful I will be watching you videos..
GREAT !!!!!!very useful video! this is such an underrated video...people need to know all of this to survive in the US
Thanks so much!❤️
Thank you so much; this video is exactly what I needed...I’ve scheduled a consultation with you later this month to get additional help in this area...you’re videos are very helpful, Thanks again 👏🏾👍🏾😌
I am so glad it was helpful! Looking forward to speaking with you : )
Thank you for your help☺️
Girlfriend you are heaven sent. I have been trying to get a breakdown for a while and you gave me everything I needed and then some. I need more help so I will be tuning in whenever I can. Do you still have the online breakdowns going?
@@mdowling835 Thank you 🫶🏾 I’m so glad to know the video was helpful. I am long overdue for creating more breakdowns but I have some posted on instagram.com/askthebiller
@@AskTheBiller thanks but I do not have instagram only youtube and facebook. I hope I will be able to find your updates on either one of these. I don't do well with social media so these two are fine for me.
I can’t stop saying thank you for these vids!
You're very welcome!! If I only had the time to make much more LOL.
Example 5 was excellent for my education on how to read my EOB! Thank you very much!!!
I’m so glad it was helpful!😊
I love the way you break this down
Thank you ❤️ I hope you learned something new 😊
Can you enlighten me with this one?
This is an example from our training. Heres the only information provided including the questions. Thank you so much in advance.
Scenario: Mark has an insurance policy with 100 Usd monthly premium , a 1000 USD deductible and a 5000 USD out of pocket maxim. He broked his leg and got a hospital bill of 10000 usd , how much of this bill he has to pay?
How much is total expenses of mark considering his deductibles and out of pocket?
How much of total expenses will be covered by the insurer?
Hi. This is not enough information. In order to calculate his responsibility, I would need to know the allowed amount on the claim and how much of his deductible and out of pocket max has been met.
very helpful I go to externship in a few days and this was my weakness I'm glad their letting me bring notes.
Thank you so much for this video and the time you put into it, to share with us all! It's so much appreciated!
You are so welcome! Thanks for watching : )
Hi Quiana! I really love how you explain each terms and gave different examples for each scenarios. May I kindly ask what is the adjustment for? and for example number 1, what the total amount of the patient is responsible to pay? is it 80? since copay is not covered by the insurance plus the 40 patient responsibility?
Thank so much in advance as this would help me to become an effective HR and I am new with the US health insurance.
Thank you for sharing this video. I just started my MOA class on billing and felt lost. I'm interested in learning more in all the medical fields
Thanks for watching, Julie!
Hi Quiana. I am really new to insurance and medical billing. In your example 4, why is that the patient responsibility is 0USD and what does remainder of their benefit year means? And does the adjustment is the amount the patient is going to pay? Thanks a lot and it will be a big help for me.
The patient responsibility is $0 because their "out of pocket maximum" has been reached. Once that amount has been reached the insurance will cover 100% of the allowed amount. Their benefit year can run on a "calendar" year, Jan 1 to Dec 31, or a "plan" year which may start on any other day of the year. This is the time period for when their benefits are eligible. Their benefits could possibly change or terminate at the end of the benefit year. The adjustment (or the amount written off) is the amount not covered. The adjustment is not the patient's responsibility if the provider is in network and participates with the plan.
So happy I found your Channel.❤ #5 stumps me still a bit. Why did we subtract the deductible but then add it back to the patient coinsurance?
Me too, thank you!❤ The insurance is going to subtract unmet deductible when calculating their reimbursement. It gets applied to patient responsibility so that amount has to be added back in along with the coinsurance. Make sense?
That was so helpful. Are those the only scenarios or is there another scenario where instead of the unmet deductible it's out of pocket maximum unmet?
Unmet out of pocket maximum is very common. That just simply means the patient continues to pay their copay, coinsurance and/or deductible. Once the out of pocket maximum has been met, the patient will no longer have out of pocket costs until their next plan year. So if they meet their out of pocket maximum on June 1st and their plan renews on January 1st from June 1st through December 31st the patient would not pay anything since the insurance will pay 100% of the allowed charges. Hope this helps!
I just finished my Administrative Medical Assistant course and i learn about medical billing and coding, you explained it very easy. Can you please provide me with the zoom information about yure class.
Hi Melisa. Thanks for watching! Here is the link with details for my billing and software training course. askthebiller.myshopify.com/products/1621013
Thank you for your video! I watched lots of videos about this topic and you clearly explained everything. You're examples helped me a lot. Thanks again!
You're very welcome : )
the amount of synapses occurring in my brain is so strong that the earth may reverse its rotation, i swear. thank you so much, Quiana.
you are a life saver !!!!!!!!!!
Thank you! So glad this was helpful : )
Thank you!
You're welcome! Thanks for watching.
This is a great video It just leaves one question what happens to the adjustment amount? Does the patient has to pay this as I assume it was billed to the patient and the insurance reimburses only the % of the allowed amount? Thank you for your advice
The adjustment is the amount written off. The patient is not responsible for that amount. Thanks for watching!
Wonderful, Thank you so much for clarifying!
THIS VIDEO WAS SO HELPFUL. THANK YOU!!!
You’re welcome!😁
If patient has a deductible and also a coinsurance, they’re deductible has to first be met before the coinsurance metric kicks in correct? - love your videos btw
That is correct! Thanks for watching 😊
Good morning,I was interested in joining your on-line refresher insurance class. I have been in the medical field for many years and have recently changed positions . In my new position I will be required to verify patients' benefits and what their cost will be for services. I found your video extremely helpful. You mentioned you have a 6 week refresher course held every Wednesday. I am interested if you still offer this class.Thank you for your time
Nancy Etter
@@NancyEtter-y7t Good Morning Nancy. Yes, I still offer the training course with included live weekly Q&A classes. Please send an email to askthebiller@gmail.com for further details. Thank you!
We are out of network provider , Can you do a video on that?
I will add this to my list : )
Only 10 comments for this very precious video...... I think still people don't know about medical billing or i think 90% of people..... They became owners of individual medical billing company 😁🤣
Enjoyed the video I hope you can do more on the calulations.You made it easier to understand.
Thanks so much!! I will make more of these videos soon : )
Can u please solve my query
Thanks so much I needed this !!
You are so welcome! Thank you for watching.
Very informative video ma'm you reminded me the stuff i forgot........ It's been a long time to left medical billing..... On monday I'm gonna face HR for medical biller....
Thanks for watching! Best of luck!
I'm working in a billing company with AR professionals and I am enjoying a lot...... Thanks to ALMIGHTY and your videos are very helpful thanks a lot 😇👍
Today's I was watching your videos again and I found my previous comments with your reply I felt smiley 😇😇
thank you so much for this infomation!!!!!
You are so welcome!😊 Thanks for watching.
Excellent explanation. Each examples are fantastic 🎉❤
Thank you! Glad you found it helpful.
Thank you so much!!!!
You're very welcome!☺
How can you tell if there is a contractual adjustment? All the fields that the EOB I'm looking at provides is: Fee charged, PDP (if applicable), covered expense, benefit paid. If there is something in the PDP fee column does that indicate a contractual adjustment?
Some of the insurance payer EOBs are more thorough than others. The best thing to do is to contact the payer and have them confirm the contractual adjustment amount. It may be on their portal/website or you can call provider services and speak with a live representative. Hope this helps!
Hi Quiana, thank you so much for this video it's very helpful. Hope you can make a video on how to read the EOB. God bless
Thanks for watching, Gina. I will make an EOB video soon : )
Ohhhhhhhhhh 💡thank you!!!!
@@PettyTenderass you’re welcome 😁
How would you calculate example 5 if they had not yet hit their out of pocket maximum but the patient responsibility of $4588 would put them over their out of pocket maximum?
Hi Shandy. The patient would only be responsible for the amount up to the out of pocket maximum. The EOB will show the amount up to their OOP max and then the insurance would pay the excess amount. Once their OOP maximum is reached the insurance will pay 100% of the "allowed" amount until their benefit year ends.
You are an amazing teacher!! Thank you so much, Quiana! :)
Thanks so much, Jeanette 🫶🏾
Thanks so much, Jeanette 🫶🏾
This was very helpful, can you explain what happens to adjustment?
I’m glad to hear that!😊 An in network provider accepts the total “allowed” amount as reimbursement in full. So the adjustment, which is the difference between what was billed and what was allowed, is written off of the patient’s account.
Loved your video! I just have a few questions about medical billing: firstly, is it possible to get into medical billing in a behind-the-scenes role? I'm interested in the field but would prefer a role that's not front desk. Also, do employers train you in understanding the insurance guidelines?
Thank you! When you say "behind the scenes role" what exactly do you mean? Not having direct contact with patients? That is possible. It depends on the scope of work you are hired for. You may not have to handle any patient inquiries and solely focus on working the claims. Most medical billers do not receive formal training and learn as they go. You can go to the insurance payers websites and see what resources they have available.
Could you possibly do a video on patient insurance eligibility/verification please?
I sure will : )
Thank you lady! I agree with the previous notes this was spot on and very clear
Thank you : )
Do business owners who want to offer health benefits need to learn this information as well?
@@codewithsharen1404 They don’t have to learn everything a biller should know, however, I think business owners should understand the basics of the health plan they purchase for employees. If they don’t understand the benefits, they should have an HR professional or insurance broker accessible to explain the plan to employees.
So i am reading over my CPC study guide. I don’t understand the RBRVS, work RVU scale thing. Is knowing how to calculate facility or non facility pricing amounts more of a coding thing or billing thing?
How do you get the allowed amount please and thank you? I'm taking a class and I'm so confused. Your video did help much more than my instructor 🤦🏽♀️🙏🏼
Hi Crissy. The allowed amount is determined by the insurance payer. If the provider is in network (they have signed a contract/agreement with the insurance) the allowed amount is predetermined and can be disclosed by provider services. The provider should have access to the fee schedule with the CPT/HCPCS codes and the allowed amounts. Unfortunately, I hear this frequently. A lot of students are not satisfied with their instructors. But I am happy to be a resource! Take care.
This was so helpful! Thank you
In your example 5, Is it possible that the remaining unmet deductibles are gradually deducted from the patients instead of full amount on the treatment from the patient.
This really clarified things for me (I'm an NP.) Let's say a patient's primary insurance is Medicare bur they have a secondary insurance, e.g., a Medicare supplement plan. I am an in-network Medicare provider but not in-network for their supplement. Do I do the calculations described in the video using Medicare numbers?
Will you eventually do a video about not in-network provider calculations?
Thanks so much!
Very best,
Abby Stuthers, NP
Just one question. So who pays the adjustments amount? Is it the patient?
Where did you get the billed amount and the allowed amount? Is billed amount the amount of service to pay?
The provider determines the billed (charge) amount and the insurance payer determines the allowed amount.
If a patient has a $1750 deductible with primary insurance. Our allowable is $1250. None of the Deductible has been met. They also have a secondary insurance that just happens to be Medicare. Our allowed amount with them is $1108.54. How do I figure out how much the patient will owe?
Hi. If this is a Medicare part B claim, I believe the patient will owe $1108.54 x 20% = $221.71. Please confirm with Medicare and let me know!
Hello. I am currently in the Medical Billing part of my online Medical Coding Course. Learning who pays first when multiple agencies invilved. Trying to understand why all don't charge the same and pay the same...
Do any of the out of pocket expenses accumulate towards the deductible? For example, if a person goes to the doctors office and pays co-pays or coinsurance throughout the year. Do those out of pocket costs go towards the deductible (until it's met) and then taken out of the total out of pocket maximum- until thats met?
Hi Markuz. It depends on the plan. Some plans will apply all out of pocket expenses (copays, coinsurance and deductible) to the "out of pocket maximum". But copays and coinsurance do not get applied towards deductible. That is a separate out of pocket expense that accumulates on its own.
@@AskTheBiller thank you very much 😊 I appreciate the quick response!
Thank you for the information. I have a question…
How is allowed amount calculated??
On what factors does it depend?
So example 3 the adjustment is $260 this giving be written off?
Because the patient is only responsible for paying the $330 allowed amount due to not met their ded?
So helpful! Thank you!
Thanks for your feedback.❤️
That was really helpful. My job, which is adjustment, is for a hospital. I'm being trained by someone who isn't very helpful. Since he has been employed by the company for more than 8 years, he is qualified to examine the account and determine where adjustments are required. Contrary to me, who comes from a nursing home and handles private billing, this is completely foreign to me. I'm not sure whether you can help with this, but if you can, that would be really appreciated.
Thanks for watching and I’m glad you found it helpful.😊 I don’t do facility billing. Only professional billing.
@@AskTheBiller Okay thank you
2 yrs later. .the last example...if pt has unmet deductible amount and 60/40 we ALWAYS subrtact unmet ded from allowed amount...then multiply it by 40% then 60%? Is that ALWAYS THE WAY ?
If deductible applies, the unmet amount is always subtracted from the allowed amount first. Then multiply by coinsurance.
Example 4 is this a scenario when a patient don’t have an ded but have an OOP with a coinsurance?
Hello, I am still confused about how to calculate the write off amount. Is there a specific formula that I need to use to calculate or determine it. In what ways there is no write off amount?
Yes, for in network claims the formula to calculate the write off amount is “the allowed amount aka the contracted rate - the paid amount = the adjustment aka the write off amount.
Thank you for explanation, a QUESTION. Does your deductible meet by service date or by claim date? I have Aetna, and could not find any info (standard saving)
Deductibles accumulate according to the date the claim was processed. For example, if you submit a claim with DOS 1/15/24 that processes on 1/30/24 and applies to deductible it’s possible that a claim with DOS 1/2/24 submitted in March processes and pays because deductible was met when the claim was received. Does that make sense?
@@AskTheBiller yes, first come-first serve. How about DOS from last yest 12/23/23 and claim was done 1/4/2024, does the same principal apply? Will that cost go towards this year deductible since claim was received this year. When i called insurance they said they go by CLAIM DATE, not the date of service, yet refusing to apply this clam towards deductible for this year.
@@annaperezlara91 they are correct. A
claim with a 2023 DOS that is processed in 2024 will get applied towards the 2023 deductible.
Hi can you explain how the Billed amount is calculated and what you mean by the amount that is “written off” is there any tax ramifications or is it just a “discount” for the services being in network?
The billed amount is determined by the provider. They can use resources like fairhealth.org to create their internal fee schedules for their services. The write off/adjustment amount is a discount for being an in network/participating provider. There are no tax ramifications.
@@AskTheBillerthank you! This isn’t addressed on any trainings I’ve taken!
Thank you! Are you still doing the courses via Zoom?
My medical billing course is pre recorded and self paced. In addition, we meet live weekly via zoom for Q&A. Please visit my website www.JustAskTheBiller.com for details or email me at askthebiller@gmail.com. Thank you!
It's a really helpful for me. Thanks 👍
You're welcome!
Awesome information sis! I like to stay versatile. This brought back some things! I use to post payments! ❤️🙌🏾
Thanks so much for watching and for your continued support!!
Thank you so much very informative 👍
So glad it was informative. Thank you for watching!
this is great. yu explain very well
thanks so much!
So detailed. Would like to take classes
Thank you! Please visit my website www.JustAskTheBiller.com. See you in class!
This was great!
Thank you! I’m glad it was helpful.😊
Hi I'm new to your channel and I love your videos. Thank you so much for making such informative videos.
Was just wondering what happens to adjustments? Is the amount the provider is willing to let go? Or should this be including for ptx oops? Thank u in advance. More power!
Hi Jane. Thanks so much for watching and for the positive feedback! When a provider signs a contract and is in network/participating with a plan, they have agreed to accept specific rates for each CPT/HCPCS code as payment in full. So the adjustment is let go as you stated because the amount in excess of the contracted rate has to be written off of the patient's account. Hope this answers your question. Take care!
Hi, my question is: If the patient has a primary and secondary Insurance. The primary deductible is 1,000 and has not met. Do you bill the secondary Ins. Prior to collecting the primary deductible? Ty in advance your video was excellent! Clare
Yes, that’s exactly what you should do! Thanks for watching.😊
@@AskTheBiller 🙂
THANK YOU!
How do you calculate the patient out of pocket amount when there is a secondary insurance? In this case Medicare is primary and the secondary has a 10% coinsurance. You’re the best!
Hi Anna. Thanks so much : ) It depends! If Medicare applies the charges allowed to the patient's deductible, the secondary insurance may or may not pay. Some secondary plans do not cover deductible. But if Medicare does make a payment, the remaining 20% is what the secondary insurance would consider and then the patient may be responsible for 10% of that remaining balance. It's hard to say! I would just explain the benefits as far as deductible and coinsurance. I don't think I would specify a dollar amount in this case.
I have a question pertaining to how the provider is payed. If a patient has a large deductible, does the reimbursement go to the provider or is it the patients responsibility to pay the provider. We have cases where the patients deductible was payed down and the provider received nothing.
Hi. When the allowed amount is applied to deductible and the insurance pays $0, you have to bill the patient. The patient has to pay the amount applied to patient responsibility.
@@AskTheBiller Thank you!
WOW I understand that awesome THANK YOU
Perfect! You’re welcome.😁
How does copay works when there is a secondary insurance?
Submit the claim to the primary insurance. When you receive the primary EOB, submit it with the secondary claim and see if they pay the primary copay. If not, bill the patient.
Thank you so much!!!!!
You’re welcome!😊
I am a registration clinic. I understand the copay part but when it comes to what the patient owes before they see the doctor with a deductible that's either met or not bet how do you figure their cost
Hi Michaelene. If the provider is "in network" and participates with the patient's plan, they have signed a contract with the insurance company and agreed to specific rates for each service. If the patient is coming in for a follow up visit you would look up the code on the fee schedule to confirm the "allowed" amount. If the patient's deductible has not been met and it exceeds the allowed amount you can charge the patient the allowed amount upfront. So for example, the patient has a $1000 deductible, $100 has been met and they are coming in for a follow up visit. The CPT is 99213 and the allowed amount is $150. You can collect $150 upfront at the time of service and submit the claim. After the claim processes confirm on the EOB (explanation of benefits) that the allowed amount and the amount applied to the deductible matches what you charged the patient. If more was applied to the deductible you would balance bill the patient the difference that they owe. If less was applied to the deductible you would refund the excess amount collected to the patient. And if a payment was made by the insurance payer and nothing was applied to deductible you would refund the patient $150. Hope this helps!
thank you!! this is so helpful
You’re very welcome! Thanks for watching ❤️
Hello good evening I did Medical Billing years ago and would like a refresher course as I started a new job that includes medical Billing. How can I be a part of your class
Hi Antonia. My refresher course covers the fundamentals of the entire revenue cycle. Here is the link and you can enroll anytime. Thank you! askthebiller.myshopify.com/products/1621013
Very good informative video 👍
Referreing to Example #5: Is the "Provider" able to keep the unmet deductible plus what was covered by the insurance? So the total income received is $5866. Did I get that correct? Thank you so much .
Hi what happen after deductible met whether the insurance pay total bill after deductible met it's correct please reply