Can a medical provider legally do this?

Houndmommy · January 2011

I met my deductible this year and so all services are covered at 100%. In Decemeber I went to a women's health boutique to get a prosthesis and some bras. This boutique accepted my insurance. My insurance paid for the items (at their contracted rate) and my EOB says "....This represents your savings, so you are not required to pay this amount. This provider is prohibited from billing the patient for the difference." The boutique is now billing me for the difference (they call it an "upcharge" and say I am responsible). I called my insurance and they say I am not responsible. Unfortunately I am stuck in the middle. Can they legally do this?

Alpal · January 2011

Not if they have an agreement with your insurer. Doesn't prevent them from trying, though. My Sis in law, recently had a situation like that with a lab. It was only about $20 and she ended up paying it just to shut them up. I'd send them a certified letter stating that according to your ins. you are not responsible for the charges and that you've reported them to the ins. company. Tell them you do not want any more correspondence from them and cc an attorney on the letter. You don't really need to consult an attorney, but make them think you have. I bet this shuts them up. Edited to add - you might also make mention of the Better Business Bureau.

lago · January 2011

If the insurance doesn't have a contract with that boutique then insurance will pay based on what they (insurance) deem as usual/customy charge for goods and services. Any charge above that is your responsibility.

Here is a link that might be helpful. It's for my state of IL but it does explain things:
http://www.insurance.illinois.gov/healthinsurance/usual_customary_fees.asp

Jaimieh · January 2011

Call the boutique and remind them that they are balance billing and since they have an agreement with the insurance company that it is against the law.

If they do not have a contract then you are responsible for the balance.

Medigal · January 2011

Make sure that the provider is "In Network" with your insurance company. It sounds like it is or the EOB from your insurance would have shown you were responsible for more payment because you went to an Out of Network provider. The providers also get the information you see on your EOB so they know exactly what you do and don't owe. Some will try any way to get more money out of the customer, so I would just call them and ask them if they need to see a copy of my EOB and I am only paying what my insurance says I am responsible for. I never pay a medical bill until I get the EOB so I can make sure I am not overpaying. If your insurance didn't have a contract with them, they would have shown you went "Out of Network" and why you had to pay more.

You are only responsible for what your EOB states you owe and make sure you let the provider know this. I would also ask them the reason they are billing me more. Best of luck>.

Houndmommy · January 2011

Thanks for you input. I am still trying to figure it all out. As usual, I feel caught in the middle. My insurance does have a contract with the boutique but I signed a paper saying I'd pay if my insurance didn't (intially there was some concern that my insurance wouldn't pay anything since this was for a 2cd breast form). So my insurance did pay but now the store is billing me for the difference. I talked to the lady at the boutique and she said she can do this as it was a more expensive breast form and the insurance usually doesn't fully cover high end forms. My insurance never pays what they are billed for any service. I explained this to her but she is still saying she can do this. She said she would go out of business if she didn't bill clients for what the insurance doesn't pay. Later she said that the only way she can offer high end breast forms is if the client pays the difference. If I had bought a cheaper form my insurance would have paid less than what she would've billed. Anyway, I'll call my insurance back tomorrow and tell them what she said and go from there.

Thanks again! Kim

lauri · January 2011

You go for it, Kim!

The EOB says the insurance company paid its contractual amount for the service billed. If the bill was above the contractual amount, it should have showed the excess as "charges not allowed" or something like that.

sounds like the boutique person is being over-diligent. I pushed back against a bill from a pathologist that was more than BCBS paid and they backed down.

Houndmommy · January 2011

Good news! I don't have to pay the difference. The boutique called me this morning and said she talked to my insurance again and that she now understands she can't bill me the difference. I am so relieved and glad that I persisted (I almost just gave up and paid it). Unfortunately for her, I don't think she really understands commercial insurance. I am guessing most of her work is with Medicare because she kept referring back to Medicare "rules". It was as though we were speaking 2 different languages at times. Then she tried to make me feel bad by saying that it wasn't fair that Medicare folks (with fixed incomes, etc.) had to pay the difference and that I didn't have to pay it. This made me mad as my deductible is $11,000 !!!!! Anyway, thanks for your posts. Being able to write my thoughts down here helped me figure out what questions to ask and you all kept me encouraged.

paintedlady · February 2011

Hi Hound

I am glad to learn that you have gotten this resolved. We certainly do not need this kind of stress added on to dealing with this disease.

In reference to medicare. I have a medicare advantage program. The medical providers that agree to accept the insurance, have to take what the the health insurnace stipulates.

I have had a similar situation happen to me but it was over an x-ray. The doctor's office called me because they were shocked at how little they were paid for the service. They wanted me to pay some additional money.

I politely informed them that since they ageed to take the insurance, I am not responsible for paying them anything more. Next (and this is important) I told them to call the Commissioner of Insurance in my state if they need any clarification of the law. When you tell them this, they realize you are informed and you know your responsibilty in the payment process They immediately back off!

Alcie1 · February 2011

I had a similar experience. I was sent a bill for what my insurance didn't pay for an office visit. The oncologist's office is in a hospital, and the hospital charged me a facility charge. The insurance company called the hospital, and I complained over and over. When the hospital threatened me with collection I paid.

I'm glad for the tip from painted lady to call the insurance commission. I will!

I dropped the doc and haven't seen an oncologist or taken any medicine in over a year, but I finally did find one that hadn't sold out to the large hospital group that has bought up all the oncology practices around here. I'll see him next week.

Can a medical provider legally do this?

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