We have recently identified instances of inappropriate balance billing related to hearing aids for our Commercial members. These errors stem from confusing the member’s benefit limit with the contracted allowed amount. This reminder is intended to provide clarity and reinforce existing requirements to help ensure that members are billed correctly for these services.

As outlined in the Harvard Pilgrim Health Care Commercial Provider Manual:

  • Harvard Pilgrim does not allow balance billing in accordance with applicable laws. Balance billing is the attempted collection of fees from members beyond the costs for which they are responsible, such as copayments, coinsurance, and deductibles.
  • Providers may only collect applicable cost-sharing from our members for covered services and may not otherwise charge or bill them. 
  • As a participating provider, you have entered into a contractual agreement to accept payment directly from Harvard Pilgrim for the amounts allowed pursuant to the agreement. You may not balance bill members for the difference between actual billed charges and your contracted reimbursement rate. 

Even if a member’s benefit limit is higher for a particular service, you cannot bill more than the allowed amount negotiated in your agreement (see the example below).

Hearing aid billing example

  • Patient Doe is receiving hearing aids. 
  • The billed amount (actual cost) is $2,100. 
  • The member’s benefit limit is $2,000.
  • Member cost-sharing is 20 percent.
  • The contracted allowed amount (negotiated rate) is $1,800.
Correct billingIncorrect and prohibited
  • The patient is billed $360 in copay/coinsurance (20% of the $1,800 allowed amount).
  • Harvard Pilgrim reimburses the provider $1,440 ($1,800 allowed amount minus $360 cost-sharing). 
  • The provider receives a total of $1,800 in reimbursement, consistent with the contracted allowed amount.
  • No further billing occurs – even though the billed amount is $2,100 and benefit limit is $2,000. 
  • Billing the member an additional $200 based on the benefit limit, to bring total provider reimbursement to $2,000.

  • Billing the member an additional $300 to reach the full billed charge of $2,100.

     

Please keep balance billing restrictions in mind when providing health care services and goods to our members. You can find additional information about the prohibition of balance billing in the Collecting Member Payment section of the Harvard Pilgrim Health Care Commercial Provider Manual. 

As a reminder, balance billing is generally prohibited by Point32Health and similar requirements apply under Tufts Health Plan Provider Manuals and/or provider contracts.