The Road Home for Health Care & Medical Benefit Solutions

What charges are you supposed to pay if you have a PPO, POS. or an HMO type of insurance plan? Deductibles and copays, right? If you receive a bill from a non participating provider, you may be asked to pay more than your fair share of the bill. In some situations you may not even know you were receiving services from a non participating provider, or even had a chance to choose a provider, which is often the case when the doctor or hospital you did choose, uses the services of providers who do not participate in your plan, or any other plans.

For instance, you my need surgery and not have a choice of anesthestists, or you may need a lab test which is rendered in your doctor's office or a hospital. The provider may choose the pathologist that meets their needs, whom they have relationships with, without regard to your health plan or whether they are using a participating provider for such services.

Insurers then, in turn, deny charges that they deem excessive and the provider bills you for those denied amounts, in addition to any deductible and coinsurancem, even though you did not choose that provider. Insurers base their denied payments on arbitrary information.

This practice is referred to as Balance Billing. Most states prohibit balance billing. Be sure to find an experienced consumer advocate who can help you get these charges removed from your bill.

As a patient, if this occurs to you, you might consider the following pre-emptive strike. Forewarned is forearmed and it is far better to play offense, than defense, with aggressive providers.

* Read and understand your managed care plan contract. Know your duties and responsibilities. Follow the rules.

* Privately inform your medial provider that you are aware of the “contract-medicine” concept.

* Confidently tell the provider to put the BB invoice in writing, under his personal signature.

* Whisper to him/her you will fax it to your employer, third-party payer, attorney, IRS, OIG, DOJ and/or insurance commissioner for a collegial second-opinion check of the amount billed.

Finally, once the problem has been resolved, politely inform the provider that true BB is illegal; and suggest that if your health plan’s compensation is too low, he/she should enlist in the plan.

Contact TeamGail for help with balance due medical bills

For more on this issue: Balance-Billing Conundrum