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Can a doctor's office do this?
Old 06-02-2014, 10:46 AM   #1
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Can a doctor's office do this?

If your insurance pays their negotiated rate for a service, can the doctor then charge you the difference? I didn't think they could, but wanted to make sure. We had an insurance mix-up with my son's dentist appt and the insurance finally paid their negotiated rate, which is about $11 less than the billed amount. The dentist office told me there was an 'outstanding amount due' and I want to know the facts before I complain about this. I told them it was due to the negotiated rate and they said they'd look into it, but knowing them, they won't and this issue will come up again. I've *never* had a medical provider try to charge me the difference between amount charged and negotiated/contract price!
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Old 06-02-2014, 11:02 AM   #2
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I've *never* had a medical provider try to charge me the difference between amount charged and negotiated/contract price!
+1 I've never had to pay the difference for an in-network provider.

We did have a dentist we really liked who was not in our network for the dental insurance so the insurance would pay him the "reasonable and customary" amount for the service provided and we would pay the difference, which was never more than a few dollars.
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Old 06-02-2014, 11:15 AM   #3
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Balance billing is regulated by federal and state laws and by the contracts health care providers have with insurance companies. Providers who have such contracts (and this is most providers) are “participating providers” or “in-network” providers, who have agreed to accept as payment in full a negotiated amount from the insurance company plus any co-pay, coinsurance or deductible that is part of your plan (often patient's responsibility). More often than not, if you do receive a balance bill from a participating doctor or hospital it is simply a billing error. Your first action should be to call the doctor’s office or hospital and question the bill. If that does not work, call the customer service folks at your insurance company.

If you seek services from a non-participating, non-network provider there are no such limits on your responsibility. In this case, the insurer may limit the allowable fee to the reasonable and customary amount for the services provided to you and then make a payment based on the terms of your plan. If the out-of-network health care provider chooses to bill you for the balance above your coinsurance and the amount your insurance company paid, , you may be responsible for the difference. However, even in this case, it is always wise to call the provider’s office and discuss the bill and the amount you must pay. You may find there is room for negotiation.
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Old 06-02-2014, 11:30 AM   #4
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Originally Posted by jowi View Post
If your insurance pays their negotiated rate for a service, can the doctor then charge you the difference? I didn't think they could, but wanted to make sure. We had an insurance mix-up with my son's dentist appt and the insurance finally paid their negotiated rate, which is about $11 less than the billed amount. The dentist office told me there was an 'outstanding amount due' and I want to know the facts before I complain about this. I told them it was due to the negotiated rate and they said they'd look into it, but knowing them, they won't and this issue will come up again. I've *never* had a medical provider try to charge me the difference between amount charged and negotiated/contract price!
Not if they are in network. But common if are they out of network. So is this provider out of network?
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Old 06-02-2014, 12:09 PM   #5
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If your insurance pays their negotiated rate for a service, can the doctor then charge you the difference?
I agree with the others here that the negotiated rate should be the only rate. Still, you need to make sure you didn't receive anything not covered and the dentist is in the provider network.

Sadly, I am finding it more common for health care providers to deliberately charge prices greater than their approved rate, refund only when requested, and even then drag their feet.
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Old 06-02-2014, 12:29 PM   #6
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Yeah... foot dragging, and... clever new ways to extort.

I don't know about dentists, but the newer game, is affiliating the doctor's office with the hospital, even though a separate building.

Our recent bills have been coming through as paid according to the medicare authorized amount for a doctor's visit... but... later we receive a balance due bill from the hospital.
Example: Doctor's total bill is $95 as submitted to medicare...We just see this as a total amount. Actually, the Doctor's bill, in the medicare submission, is $65 for the visit. That's what medicare pays. The other $30, is a "Facility Fee"...not paid by medicare in our case, as the visit didn't require hospital services.

Here's an article that discusses this... not a totally new thing, but new to us...

Day 2: ‘Facility fees’ add billions to medical bills - KansasCity.com
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Old 06-02-2014, 12:36 PM   #7
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Our dentist is out of network, but the insurance "reasonable and customary" usually covers the bill. Once in a while we get a bill for $2, when the price increases a little before the insurance payment.

I have never had a problem with a negotiated payment (in network), although I have agreed to pay for some things insurance didn't cover. All my providers have been very careful to refer me to other in network providers.
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Old 06-02-2014, 12:41 PM   #8
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Thanks - this answers my question. I went to this dentist because it was in network but was told later it wasn't in network and then told later it was in network - LOL! (Not really laughing) There has been so much cluster#u@&ery (pardon my French) since my son's appt in JANUARY that I won't even go into it all. I just hope this is the last incidence of it, or I will change dentists.
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Old 06-02-2014, 12:44 PM   #9
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Quote:
Originally Posted by jowi View Post
If your insurance pays their negotiated rate for a service, can the doctor then charge you the difference? I didn't think they could, but wanted to make sure. We had an insurance mix-up with my son's dentist appt and the insurance finally paid their negotiated rate, which is about $11 less than the billed amount. The dentist office told me there was an 'outstanding amount due' and I want to know the facts before I complain about this. I told them it was due to the negotiated rate and they said they'd look into it, but knowing them, they won't and this issue will come up again. I've *never* had a medical provider try to charge me the difference between amount charged and negotiated/contract price!
In my experience this is typical with my out-of-network dentists but not with in-network medical charges (doctors, hospitals, tests, etc.).
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Old 06-02-2014, 01:49 PM   #10
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Talk to your insurance company. My insurance company sends us a notice that shows the billed amount, the allowed amount, the amount they paid, and the amount I owe. There is an accompanying statement explaining that the bill either is or is not in-network. If it is in-network the total paid between me and the insurance company equals the allowed amount. If it is out-of-network, the insurance company pays and the rest is my problem.

But if you have deductibles or copays, you may owe something on top of the insurance payment to a in-network provider.

My dental insurance tends to cover less than my medical. It could be described as a cost-sharing policy for most things.
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Old 06-02-2014, 02:37 PM   #11
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Not to get off topic, but during a routine check-up last week, my PCP announced that effective Jan 2015, he would no longer accept ANY insurance!

His business model is this: a huge portion of his cost is labor to handle insurance forms, coding, fighting with insurance companies etc. (this is NOT a concierge approach)

If he gets rid of all that, he can charge a little more than my current co-pay, spend "more than the 15 minutes allowed by insurance and thus give better care" and make more money. "I want to be a doctor, not a paper pusher...".

Interestingly, my grandfather's PCP did that 35 years ago...just stopped taking insurance and charged $30 a visit.
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