Balance Billing Question

Balance billing no nos only applies to providers who belong to the network. Let say you have PPO and your ENT is a preferred provider for that network, meaning he is contracted with your insurance company to accept x $ for the service provided, he should not be able to bill you for the remainder of the bill.

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Melanie is right there are other things you may be paying for but this does not fall under the definition of balance billing ( although it may be what you are referring to and are paying for). These are referred to as copays and deductibles.

By definition, deductibles are the $ amount you have to pay for before the insurance share of the bill kicks in.

Co pays are the percentage $ amount you are responsible for.

Copays and deductibles vary from contract to contract depending on what contract you have.

To know if you are being balanced billed:
Check your EOB (Estimation of Benefits). This comes from your insurance company. It should list the fees, applicable deductible and copays as well as what your insurance pays. If you receive a bill from a provider that is basically the difference between what is paid by your insurance and what the balance in fees (after deductible and copay) then yes you are being balanced billed.

Scanned your article BTW and there is a good point --some consumers assume that just because the facility (hospital) is a par facility provider does not mean the provider (doctor) is. Therefore the doctor can balance bill. (This may be the case for Rebecca P.)

As far as the ADHD testing, chances are it is not a benefit. In my experience these things are rarely if ever paid. And yes, the insurance co can take back monies paid.

Dawi is correct. If the provider is contracted with your insurance or in-network, then it violates his contract. If you are seeing an in-network provider, you need to call your insurance co and make them deal with the provider. If you are seeing someone who is out of network, then they can charge you whatever they want.

If both of these doctors were a preferred provider on your insurance and you paid the co-pay, the doctor should not have billed you the remaining balance. A preferred provider doctor has signed a contract with the insurance company that states they are willing to take a substantial pay-cut to receive referral patients through such insurance companies. Many times this is such a substantial cut that doctors have to double books patients (hence the long waiting times and a mere 5 minutes to spend with you) just to make ends meet. And, some resort to billing the patient the remaining balance (which is unlawful if they have signed a contract with the insurance). But, if they were out-of-network providers, they can take payment from the insurance where your insurance would pay say, 60-70% of the bill and you would owe the remaining balance. Did you get an explanation of benefits from your insurance showing what was paid to the doctor and what was your responsibility? It will clearly state what the "discount" was and if your doctor is billing you for this he can be turned into the insurance company for breach of contract. Any more questions just let me know!!

Even if your doctor is contracted with your PPO, you may still have a copay or a percentage that you owe the doctor. Our dental office contracts with several PPOs and I have to write-off the PPO savings, but there is usually a patient portion that is owed to us. Very few insurance policies pay for visits, tests, etc. at 100%. You need to review your benefits policy to determine the copays and percentages for which you are resonsible.

Dawn is right on. You need to find out if your doctor is contracted with your insurance company. If not, you owe the difference between what the doctor charges and what your insurance pays.

I agree with what is said below. . .we have been on several PPOs through the years and they all work a little differently. Some have deductibles, some don't. Some have specific co-pays (like $15/visit) and some have you pay a percentage of the contracted amount. The key is not paying anything ABOVE the contracted amount. The amount paid to the provider plus the amount you are expected to pay should equal the contracted amount. Anything over that should be written off by the provider.

So you need to educate yourself about your plan. Your plan may have a website to explain YOUR exact benefits. Start with calling the number on your card and ask how you can get a complete description of your benefits. However, I will say, that $17 each for weekly allergy shots seems high for a co-pay, so definitely get that clarified. Good luck!

It may be deductible, copayments, or coinsurance. Your best bet is to ask the insurance company: what the billed amount, allowed amount, amount paid, and your patient responsibility portions are, and verify that he is indeed a network provider for their company. Anything above the patient responsibility portion (ded/copay/coins) is balance billing. If he's preferred or participating with your insurance company, he shouldn't be allowed to bill you anything but these amounts, under his contract with the insurance company. Sometimes bills come late, a year is a bit late, but if they had to rebill, send documentation, etc. then it happens!

this has happened to us before with the hospital my daughter was born at and the dr who took care of her he billed me a year after she was born and i called the insurance company and the hospital billing department and had them send me a copy of how much every thing was and how much the insurance paid