Posted on 09/06/2008 8:56:26 AM PDT by DeaconBenjamin
In a controversial practice known as "balance billing," health-care providers are going after patients for money they don't owe
As health-care costs continue to soar, millions of confused consumers are paying medical bills they don't actually owe. Typically this occurs when an insurance plan covers less than what a doctor, hospital, or lab service wants to be paid. The health-care provider demands the balance from the patient. Uncertain and fearing the calls of a debt collector, the patient pays up.
Most consumers don't realize it, but this common practice, known as balance billing, often is illegal. When doctors or hospitals think an insurer has reimbursed too little, state and federal laws generally bar the medical providers from pressuring patients to pay the difference. Instead, doctors and hospitals should be wrangling directly with insurers. Economists and patient advocates estimate that consumers pay $1 billion or more a year for which they're not responsible.
Yolanda Fil, a 59-year-old McDonald's (MCD) cashier in Maple Shade, N.J., got tangled up with balance billing after gall bladder surgery in 2005. She and her husband, Leon, a retired state transportation worker, have coverage through Horizon Blue Cross Blue Shield of New Jersey. Horizon made payments on Fil's behalf to the hospital, surgeon, and anesthesiologist. Then, in 2006, Vanguard Anesthesia Associates billed Fil for an unpaid balance of $518. Soon, a collection agency hired by Vanguard started calling Fil once a week, she says. Although she thought her co-payment and insurance should have covered the surgery, Fil eventually paid the $518, plus a $20 transaction fee. "I didn't have any choice," she says. "They threatened me with bad credit."
(Excerpt) Read more at businessweek.com ...
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With the Federal Blue Cross/Blue Shield they tell you that you don’t have to pay the balance because they have paid the agreed amount when the doctor/dentist signed up with them.
Had some of the places try to collect, threaten a bill collector, and then I tell them to check with Federal BC/BS and give them the number and then call the local Federal BC/BS — their calls and letters stop.
They do it to my Mom all the time and I refuse to pay her bills like this but if I wasn’t handling it, I am sure she would pay.
We had one that threatened to ruin my Dad’s credit so he couldnt’ buy a car last year and he died in May ‘97. ou should have heard my comment to that remark. Believe they prey on senior citizens.
Now this is the kind of stuff conservatives should make issues about w/regard to health care!
Last year I put too much eye cream on my eyes....they puffed up and I ended up going to emergency thinking I would get quartazone or something.....Emergency room wait 2 Hours....Bill was covered.....Seeing the doctor for 15 minutes telling me your eyes will heal themselves....$380.00....I ended up paying $75.00 because I have 2 coverages.....Oh and I’m still paying for the one night stay back in “06” and Hunterdon Medical Center for 1/2 of my thyroid being removed...the bill was $13,000....my balance $1,000......Unbelieveable......
It should be pointed out, however, that patients are only exempt from paying the balance IF the provider has signed a contract with the insurance company whereby he/she agrees to accept the insurance benefit as payment in full.
if the anesthesiologist was not a contracted provider of the health insurer, then the balance due is owed by the patient.
when having any kind of medical examination or procedure, the patient needs to verify that ALL of the participants in the procedure are contracted providers of the health insurer.
sometimes, the primary care physician is a contracted provider but the other members of team are not.
this puts an unreasonable burden on the patient who is not in a position to determine the status of all the providers.
IMHO
A co-worker had a similar problem with a dental group. She ended up getting a lot back once she figured out what they were doing. She had to get our insurance carrier involved.
If they do so, and they are prohibited from doing so by law, then they have just committed mail fraud. This gives you VERY good leverage to get them to back down.
Oh and I’m still paying for the one night stay back in “06” and Hunterdon Medical Center for 1/2 of my thyroid being removed...the bill was $13,000....my balance $1,000......Unbelieveable....
In my state (New York) balance billing is legal as long as you do not participate in an insurance plan (Medicare excepted - see below).
For example, I see a patient in the office as an out-of network patient (i.e. I am not participating in their insurance plan). My bill is for $500.00. The insurance pays the patient $400.00 - what they “allow” for my services. Because the patient has the contract with the insurance company, not me, I legally bill for the balance of $100.00, and the patient is legally bound to pay it.
Now, if I participate with the patient’s insurance, I am legally bound to accept the insurance plan’s payment (of course, if there is a deductible or a co-pay, the patient must pay that).
Medicare is different inasmuch Medicare limits what a doctor can charge for a given service. So, of my usual $500.00 fee, Medicare my say that I can only charge $250.00 - so I write off the other $250.00. Of the $250.00 that Medicare allows, most plans pay 80% (unless the annual deductible has not yet been met). Medicare requires that I bill the patient for that 20% and any deductible, and the patient is bound to pay that, either out-of-pocket or by secondary insurance.
Moreover, Medicare requires that a patient sign a waiver at every time of service, indicating that if Medicare rejects a claim as being non-covered, that the patient will be responsible for the bill.
This applies to things like Travel consultations and immunizations - if I don’t get that waiver signed, I cannot legally bill the patient for the consultation, and any vaccines administered (yellow fever, typhoid, polio, hepatitis A, etc), even though I have provided the service in good faith.
Medicare rules apply to all beneficiaries, no matter their income - the pensioner on a fixed income pays the same as the retired CEO with 5 homes and 4 cars.
thank you for posting this thread. I had never heard of the practice before..... I have heard of billing patients prior to billing the insurance company though. I heard that was a big no no too.
This needs to be in BOLD letters.
Read your insurance contracts!!!!!! This generally applies to PPO's and HMO's. You are otherwise responsible for all charges your insurance does not cover.
As for anesthesiologists, and many radiologists that may provide services to you, a lot of them do not contract with any insurance companies. They are usually independent from any hospital or clinic in which they practice. So if you get a bill from them, you probably owe it. Look at your insurance contract, and call them if there is any questions, they will help you sort it out.
Anesthesia and certain other things are sometimes not covered or may be “out of network”. When I had my kids some 20 years ago we had BC/BS of Central NY, and they paid everything (I don’t even recall a copay) except the anesthesiologist. I paid them $300 out of my own pocket.
The above case I don’t know why the woman didn’t just call her insurer, they would have explained it and told her whether she owed anything or not.
This whole credit rating thing is nothing but a 21st Century Mafia scam, intimidation and extortion scheme. Live frugally, eliminate your debt and tell them to stick it where the sun doesn’t shine.
“That actually seems to be a fair deal. 1/13th of the total bill and 12/13 covered by some one else. I wish I could only pay 1/13 of my electric bill or mortgage.”
You could, if you paid for electric bill or mortgage insurance. That’s who the “some one else” is that pays 12/13 of the medical bill...it ain’t free.
Welcome to FR.
No, we don't expect socialism in healthcare. In fact, we just DEMAND that doctors and insurance quit playing fraudulent games with the public.
We PAY for health insurance. It is not "socialism" to expect to get what we have contracted for.
It is this insurance/doctor gamesmanship, along with ridiculous malpractice awards, that has driven the costs of healthcare through the roof.
My cousin a GP in New Mexico says that ‘balance billing’ is simply charging the difference between the paltry amounts insurance or medicaid pays and the ACTUAL charge. She gets about $47/hr medicaid — compared to her plumber who gets $100 (cash with no paper work or office staff)!
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