How To Dispute Balance Billing From Out-Of-Network PPO HMO

The patient visit the doctor. The doctor issues a bill to the insurance company. The insurance company pays the doctor a discounted payment and send you are copy of the bill. The doctor sends an additional bill to you. This controversial and, yes, illegal practice is called Balance Billing. Many states have already pass laws making Balance Billing illegal.

Under Medicare a federal law makes Balance Billing illegal as well. However, Balance Billing still takes place, mainly because the public is aware of it. In the event you receive a bill from you in-network provider to which your insurance company has already issued a discounted payment call your insurer for guidance.

Many of these cases take place with patients who are in an PPO or HMO network and visit an out-of-network physician, specialist or lab. HMO policies restrict you from visit an out-of-network doctor unless patients have preapproval or referral from their physician. PPO pays up to 80% of medical cost for services within the network, but in out-of-network patients pays more. Preapproval or referral in an PPO or HMO network does not necessarily mean that fees will be paid.

Sometimes the provider is looking to be paid more than what the insurer agreed to cover and so sends an additional invoice to the patient. This is ugly and surprising side of insurance coverage is Balance Billing. Many times the patient just pays the doctor without negotiating or seeking redress, partly because patients are concern about what this could do to their FICO or credit score. However, there are ways to prevent Balance Billing and to fight against paying the doctor when the insure has already paid.

Avoiding Balance Billing

The first thing you should do as a plan holder is to stay within your network, except, of course, in the event of emergency. Patients have the tendency to go out-of-network to visit a doctor partly because the doctor may have a good reputation in the community or come highly recommended. Seek advice and find qualified, reputable physicians within your network. That way you are assured that medical cost are covered.

Do not take it lightly. Double check with your physician to ensure that he is within the network. Doctors move in and out of network as  the network requires physician to meet certain guidelines set by the insurer. In some cases, even if a hospital or lab is within your network, some of the specialist who treat you may not.

Negotiate Prior to Visit

Patient who intend to visit a specialist out-of-network should negotiate fees before receiving treatment. Most doctors within your community will give discount on cash payments. The fee you negotiate should be based on what insurers are anticipated to pay – what they think is usual and customary fees.

For PPOs the insurer could pay as much as 80% of fees, so you can negotiate the price on the remaining 20%.  If the doctors charges you much more than the 25% of the total amount your insurer paid, you may be Balance Billed for the difference. Request an estimate from the out-of-network doctor before treatment.

Double check the amount with your insurer to verify what the doctor charges are reasonable. With this information in hand, you now have negotiating power to pay a low fee to the doctor.

In the event you are dissatified with the amount the doctor charges you can file an appeal. You will have to contact your state’s insurance office for more information on filing an appeal

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