Balance Billing from provider

[bhwang12]

It's allowed because there isn't a law that says it's not allowed. (State specific exception noted above)

And the provider, or at least his billing office, WILL be involved in permitting the reduction.

I spoke to the provider (doctor's billing office) and I was told they would not accept taking the reduced amount and they want either the insurer or myself to pay for the balance.

 

[bhwang12]

it doesn't matter if it is law or not. What matters is what the policy states. As long as the action within the policy is not contrary to any laws, it is a matter of contract.


You need to understand the insurance policy (in what you are speaking of) is a contract between you and them. They can include whatever rules they want to include, as long as it is not contrary to existing law. The doctor, if an in network provider, does have a contract with the insurance company. In that, generally the doctor agrees to take what the insurance company determines to be the proper amount of payment with no recourse allowed for the doctor (other than something such as appealing the matter based on an improper classification of the procedure or such).

so, the only real issue is whether this provider can bill you for the balance. As you should have seen in the discussion, there are situations where it is allowed and situations where it is not allowed in NJ when dealing with a manage care system and an out of network provider. Care to shed any light on the information needed to make that determination?

It does matter if it is a law or not because if it is, then the doctor has to abide by it. Which means that he cannot bill me for the full amount of the surgery and has to accept the 50% reduction for the second surgery.

Sure, what kind of information is needed to determine if the balance billing is allowed or not in MY specific situation?

 

[justalayman]

So, depending on where this fits within the law, either your insurance company or you are liable for it then so until it is determined who is liable for the amount, who you need to deal with is on hold.

 

[justalayman]

Presumably the policy is a Ppo, HMO, or some other managed care system.

From what I read and cbg posted, how you ended up with this doctor will determine if your insurance company is liable for the payment or you are so..

You say you went to the ER. Did the hospital call in this doctor to perform the work at their facility? Or did you source the doctor yourself and possibly have the work done elsewhere?

 

[cbg]

I spoke to the provider (doctor's billing office) and I was told they would not accept taking the reduced amount and they want either the insurer or myself to pay for the balance.

Then unless the exception in the law applies here (j/k has addressed what information we need in order to say if it does or not) there will not be a reduction. Unless the exception applies, the law does not entitle you to one; it simply does not prohibit one.

 

[bhwang12]

Presumably the policy is a Ppo, HMO, or some other managed care system.

From what I read and cbg posted, how you ended up with this doctor will determine if your insurance company is liable for the payment or you are so..

You say you went to the ER. Did the hospital call in this doctor to perform the work at their facility? Or did you source the doctor yourself and possibly have the work done elsewhere?

Yes, I went to the ER and they called in the specialist doctor to perform the surgery at the ER facility. I did not have time to do anything like source the doctor myself or even discuss any options. Basically, I was told by the person working at the ER that the surgery would be complex so it would be best to bring in a specialist to take care of it because there isn't anyone else suitable to do the job within the hospital.

 

[cbg]

Was the ER in-network?

 

[bhwang12]

Was the ER in-network?

Yes, ER hospital is in-network.
Doctor that was called in is not.

 

[cbg]

Okay, this sounds as if I'm splitting a hair, but it's a very, very important hair.

I understand that the hospital that the ER was in, was in-network. That does not necessarily mean that the ER itself was in-network.

We need to know if the ER, not just the hospital, but the ER itself, was in-network. I have recently been seeing, for at least one major, national insurance carrier, ER's listed separately from the rest of the hospital.

You may need to get that information from the insurance provider.