Case of the I Need the Rest of My Money

Peggy is the Insurance Specialist for Dr. Jay Smith, an orthopedic surgeon here in town. She is responsible for medical billing, benefit verification, posting of payments, patient invoicing and all claim appeals and disputes.

Peggy has just confirmed eligibility and benefits on a 16 year-old new patient, who is an avid tennis player. She is coming into the office today with the complaint of right wrist pain. Peggy learns that:

  • The patient has been an eligible dependent since 2010.
  • The plan is a PPO plan.  
  • Patient has no secondary plan.
  • Deductible of $1200.00 has been met in full.
  • Plan pays 90% in network and 70% out of network.

The patient is seen, diagnosed with severe Carpal Tunnel and scheduled for surgery. The surgery is performed and the claim for $5000.00 is billed to the health plan.

Since Dr. Smith is out of network, the patient was required to pay $1500.00 (30% of the $5000.00 charge) prior to surgery. Peggy expects the health plan to pay $3500.00 (70% of the $5000.00 charge).

32 days later the plan issues a payment of $1235.00 for this claim. What happened? Where is the rest of the money? Should she appeal? Bill the patient?   


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