Balance Billing

[lovemygirls2]

What is the name of your state (only U.S. law)? Texas

I have been trying to find laws and/or codes regarding balance billing.

I have a medical provider that is contracted with the health insurance company. According to EOBs from health insurance all that is owed is co-pays of $20.00 per visit.

The health insurance has been being billed for treatment received as a result of a personal injury by the provider. There is a lawsuit which is currently in negotiations with hopes of settlement.

In trying to settle I checked with the medical provider and was given a balance that was minus the payments made by insurance, without any contractual adjustments per contract with health insurance. I also have a subrogation lien with the health insurance for the amount that they have paid out due to the accident.

Really, all I want is to know if anyone can point me in the right direction on the legality of an in-network provider balance billing the patient for charges that they have billed to health insurance. The only things I have been able to find so far only talks about out-of-network charges.

Thanks

[ecmst12]

It's NOT legal for them to balance-bill you when they have a contract with your insurance. The subrogation lein that you will owe your insurance company has nothing to do with them - if you have paid your copays, then the doctor has been paid in full.

[tranquility]

What does your insurance company say?

It's their contract which is breached. If you complain to the insurance company, they might just give the provider a call.

[cbg]

What you need to do now is contact the Provider Relations (they may call it something else but it's the department that contracts the providers) Department at your insurance carrier. It is their responsibility to see that the contract is followed from both sides. If the provider is balance billing in violation of the contract, they can help you.