HMO out of Network payment

[Tigerlady1]

What is the name of your state? Pennsylvania. What is the minium percentage that a HMO (Health America/Value Options) is required to pay an out of Network Provider? I have been in ongoing treatment with a Mental Health Clinic. I was under Blue Cross/Blue Shield but had to change to Health America because of cost. I am now told that if my Mental Health Clinic does not accept the offer of Health America, I am libel. The option to have Health America pay their amount & I will pick up the difference, will not even be considered - by Health America. My clinic tells me the reason they don't participate in Health America is that they don't pay. Is it possible Health America offers such an unreasonable payment, forcing places to reject the offer? Need help desperately. I'm on Long Term Disability & have a limited income.

 

[purple2]

Your insurance policy is the only place to find an answer to the question of what is covered.

If the clinic had a contract with your insurer, then the contract might have required them not to bill you for the balance of what the insurance didn't pay. However, you are saying that the clinic does not have a contract with your insurer. Health providers are not required to sign contracts with HMOs, and they are allowed to set their own prices. You as the patient would be liable for all costs you incur for services you receive.

Your options are: pay the price you are being billed, try to negotiate a discount with the clinic, or to not receive services at that clinic.