andWe have to pay for services at the time of service
What part of this do you not understand?explanation of benefits it says "you need to request a refund from the provider
andWe have to pay for services at the time of service
What part of this do you not understand?explanation of benefits it says "you need to request a refund from the provider
School me a bit on this one somarco, seriously. I want to understand this. It could eventually be me in this situation.somarco said:Carriers do not have discounts.
PPO networks (MCO's) are the ones who hold the contract with the provider.
Inferences are fine but mean nothing, particularly in this case.
Health Link has discharged THEIR liability when they paid the claim. This is now an issue between the patient and the provider.
Don't know if this applies or how it would affect the OP's situation but Healthlink and Healthpoint have merged with Anthem.(not sure it is the same Anthem as refereed to in this post)In this case, the OP has indicated their carrier is Health Link. Perhaps this is another name for Blue in their area. Blue goes by different names in different areas. In some cases they are Anthem, Wellpoint, Unicare, Lumenos and other names. If Health Link is a Blue organization, then they may well contract directly with the provider.
.True except the discount. It would seem the discount was improperly applied and the billing should have been treated as a non-provider or out-of-network provider and wasn't.There is nothing to indicate there is a direct relationship between Health Link and the provider
I totally agree, see answer above in this case.The other issue, which really negates any influence the carrier has over the situation, is the fact the provider is not accepting assignment of benefits, is not billing the carrier, is not accepting payment from the carrier. Therefore the carrier does not have any means to enforce compliance with the negotiated fee structure.
I did not restrict my stand to a "carrier's responsibility". I also included what seems to be the situation. A improper EOB was issued that seemed to treat the provider as a preferred provider.You & averad can continue to maintain it is the carriers responsibility to intervene but that does not make it so. The carrier has discharged their liability and made it known this is not their battle.
.apparent1)The provider does not accept assignment of benefits
.correct, as posted in original post2) The provider does not bill carriers
correct3) The provider has refused to respond to requests from the patient to honor the fee schedule.
correct4) The carrier has indicated they can do nothing
very possible5) This has continued for 8 months without resolution and most likely will continue in a stalemate unless a court awards a judgment in favor of the plaintiff
believe it or not, there is not enough info to put it into a "sue them" category. The OP may be regulated by their agreement to others means prior and possibly excluding a lawsuit6) This thread is way too long as Senior Judge offered a definitive response and that should have been the end.
NO, I have done none of the above. As I just stated, all the facts have not been presented to make a definitive ruling on the situation. Even you (somarco) have eluded to the possibility of your advice being wrong by acknowledging your ignorance as to a possible Health Link/ BCBS connection.7) Beaufort, averad and you (layman) have ignored and/or misunderstood the facts and have kept this thread going with my help.
I wasn't aware anybody here was ever "on the clock" but your continued input was informative to me and I believe it to be germane to the OP's situation.8) I am now off the clock for this thread
Health Link is a PPO and HMO provider http://www.healthlink.comsomarco said:MOST carriers do not have a direct relationship with a provider. This statement was qualified earlier. Blue is one of the exceptions. HMO's are another.
Most other carriers do not have their own network but rather rent a network from companies such as PHCS, Beech Street, Great West and so forth. As such, there are no contracts directly between the carrier and the provider.
In this case, the OP has indicated their carrier is Health Link. Perhaps this is another name for Blue in their area. Blue goes by different names in different areas. In some cases they are Anthem, Wellpoint, Unicare, Lumenos and other names. If Health Link is a Blue organization, then they may well contract directly with the provider.
There is nothing to indicate there is a direct relationship between Health Link and the provicer.
If Health Link is an HMO, then they may well contract with the provider. However, in this situation, it seems unlikely that Health Link is an HMO.
The other issue, which really negates any influence the carrier has over the situation, is the fact the provider is not accepting assignment of benefits, is not billing the carrier, is not accepting payment from the carrier. Therefore the carrier does not have any means to enforce compliance with the negotiated fee structure.
You & averad can continue to maintain it is the carriers responsibility to intervene but that does not make it so. The carrier has discharged their liability and made it known this is not their battle.
And this . . .
If the provider feared any repercussion from the carrier, they would have refunded the overcharge when requested. For what ever reason the provider feels they are immune to punitive action, especially from the carrier.
In summary:
1)The provider does not accept assignment of benefits.
2) The provider does not bill carriers.
3) The provider has refused to respond to requests from the patient to honor the fee schedule.
4) The carrier has indicated they can do nothing
5) This has continued for 8 months without resolution and most likely will continue in a stalemate unless a court awards a judgement in favor of the plaintiff
6) This thread is way too long as Senior Judge offered a definitive response and that should have been the end.
7) Beaufort, averad and you (layman) have ignored and/or misunderstood the facts and have kept this thread going with my help.
8) I am now off the clock for this thread.
The Insurance carrier should not be placing this on their eobs if the provider is not contracted. This will confuse members and cause problems with providers.Craftmasters said:"you need to request a refund from the provider on the discounted amount. Be sure to make a copy of this EOB and send it in with your refund request"