HMO and Dr billing practices

[SarasDad]

What is the name of your state? FL
I was referred to a clinic by my family physican that is under my HMO policy. I have received several bills for services (doctor, facility, nurse, lab). After checking the paid claims, it looks like they were adjusted to the HMO schedule of charges, but they want me to pay for a portion of what the HMO did not cover. As I read my policy (Blue Cross/Blue Shield HMO) I am responsible for only the copay (one only, as the form I signed was for the clinic). However, the doctors office said I signed a statement that I would be responsible for all charges relating to my care. I took that to mean my obligations according to the HMO policy that both me and the clinic/practice abscribe to either as a subscriber or service provider, and were approved to do the procedure. Question: is the physican and associated service providers wrong in demanding additional payment from me or am I right in saying they were provided a copay and I owe you nothing more?

[moburkes]

What additional charges? If the additional charges are for services not covered by your insurance, then you owe that entire amount. Have you satisfied your deductible yet?

[cbg]

IF you are being charged for the amounts over and above the agreed-upon rate between the provider and the carrier, then no, this is almost certainly not allowed and you should contact the Provider Relations department of your HMO to tell them you are being "balance billed" and they should take care of it for you.

If, however, these are, as moburkes suggests charges that are either not covered by the plan or which are applicable to the deductible, then yes, you still owe these charges.

[lealea1005]

In addition to mo and cbg's answers, the PCP referring you may have been a participating provider, but that doesn't mean the sub-specialist was. If the sub-specialist/nurse/lab do not participate with your health plan, they are permitted to balance bill. AND....in many states a Physician is permitted to contract with the PPO and POS part of the health plan but not the HMO. It can be tricky.

[SarasDad]

So, if I undertand some of the replies here... I am an HMO member. I am referred and approved by my HMO for treatment at a clinic that is a contracted provider for the HMO. I pay a $20 co-pay. The clinic bills me, I call them and remind them I am under the HMO, they bill the HMO. The HMO then adjusts their reimbursement to the negotiated rate the provider (clinic) and the HMO agreed upon. The clinic then turns to me and says I owe the rest and I am obligated to pay it? If it was a PPO i understand I might have to pay 20% or such. But the premise of an HMO co-pay. That sounds like the entire premise of joining a HMO is a scam, in that the only costs controlled are the HMO to the provider costs, while the provider is free to bill the subscriber (patient/me) what ever they deem necessary, and the promise of a deductible only policy with low out of pocket is false? If that is the case, why would anyone buy an HMO policy? And I'm not a lawyer, but would any lawyer sign a from obligating you to pay for treatment and services, not knowing the costs in advance? It sounds like this is a huge case action lawsuit waiting to happen.

[moburkes]

No. No one is saying that.

[ecmst12]

You need to determine if the specialist you saw is actually contracted with your policy or not. Your HMO customer service can tell you that. If they are not contracted, then yes they can balance bill you. If they ARE contracted, then they are prohibited from balance billing you and your HMO customer service should also be able to help you with that.

However, there ARE circumstances when a contracted provider can bill you for charges that the HMO denied; it depends on the reason for the denial. So you need to find that out as well. If it is just the amount over the contracted rate that they are billing you, then they definitely can't charge you for that. But if they deny something as not covered under the plan, or not medically necessary, or cosmetic, etc, they may be able to bill you for it. Depending on the situation, you may be able to work something out with the provider if there are charges that you are responsible for.

[cbg]

Okay, here are some examples.

Example 1:

We will assume a $20 copay and a bill of $100. We will also assume that the procedure is covered by your HMO and the provider is covered under the HMO's network. The provider and the HMO have a contract in which the HMO will pay the provider $69 for this procedure.

You pay your $20 copay. The provider submits the bill to the HMO for $80. As provided by the contract, the provider pays $69, leaving a balance of $11. The provider may NOT make you responsible for the $11.

Example 2.

As before, we will assume a $20 copay and a bill of $100. We will assume that the provider is under the HMO network and the provider is due $69 under the terms of his contract with the HMO. However, in this example, the procedure is excluded from the policy.

You pay your $20 copay. The provider submits the bill to the HMO for $80. As indicated by the policy, the HMO declines payment. The provider bills you for $80 - you DO have to pay it.

Example 3:

Assuming the $20 copay and a $100 bill - a covered procedure, and a non-network provider.

You pay your $20 copay. The provider bills the HMO for $80. Since the provider is non-network, depending on the terms of your policy either the $80 is applied to your deductible or the claim is denied. The provider bills you for the $80. You DO have to pay it.


Is that any more clear?