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Author Topic: Is Suprise Medical Billing Allowed In Your State?  (Read 1223 times)
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« on: October 17, 2018, 07:48:15 PM »

While I understand balance-billing, I can't say I agree with it. I mean, in the ethical sense it seems sort of....shady. Am I wrong to feel this way? My husband pays Medicare and Aetna and we deal with a high annual deductable/copays and on-top of that, get a "surprise bill" from a doctor that treated him at the ER because that doctor isn't in Aetna's network. Aetna did pay him but a lower fee. And believe it or not, Medicare also paid him, and a pretty penny I might add. But the doctor still wants to be paid 100% of what he charges so has billed us the balance. That's understandable but being on an 80-20 plan, we thought that meant "100 percent coverage". We were, well, surprised to get a bill from the doctor at the ER. Especially since we checked earlier with Aetna to make sure this hospital was "in network". What we didn't know is that we'd also have to check if the doctors, pathologists, radiologists, etc were ALSO in-network. Surprise, surprise! Just because an ER may be on your insurance list as being in the network, staff working there MAY NOT be! See what I mean by "shady"? Guess that is what they call "buyer beware". Only this kind of leaves you feeling violated. Not ripped off, just violated. Of course we are grateful to all staff at the hospital but have to admit, when you're paying for insurance then excuse me, but what the heck are you paying insurance for? Anyway, some states protect against balance-billing some don't. Some only protect the consumer if the surprise bill OOPS...balance billing is over $500. Here's a link that I hope will make it easy for anyone reading this to look up their own state.

I copied this particular paragraph from the link.

Consumers buy private health insurance coverage to protect themselves from the high cost of medical care. They expect that if they pay their premiums and use in-network providers, their insurer will cover the cost of medically necessary care beyond their specified copayments, coinsurance, and deductibles.
An in-network provider is a physician, hospital, or other health care provider with whom a health plan has negotiated a payment rate. As part of its contract with the plan and typically required by state law, the in-network provider agrees not to charge the plan or enrollee more than the negotiated rate. By contrast, an out-of-network provider has no contract with the health plan and thus no negotiated payment rate. When an enrollee is treated by an out-of-network provider, the health plan will often limit its payment to an amount that it determines is fair. When this happens, an enrollee may be billed by the out-of-network provider for the difference between what their health plan paid and what the provider charges. In some cases, enrollees face thousands of dollars in charges—referred to as “balance bills”—above their expected cost-sharing.1

Here's the link. It should include a list of states.


I'm glad that when I go to the store to buy a carton of milk that I don't end up getting a bill in the mail from the dairy farmer in addition to what I paid the store. Or is that a bad analogy? It's just a bit unnerving to know that there are doctors who want more money in addition to what they've been paid by insurance companies. Or is it the hospitals who employ them that are shady? It's not necessarily the dollar amount of the bill but for us, it's the point. We want to take a stand and not pay. Hello debt collectors!!

oops...had to self-edit to add the link I forgot.
« Last Edit: October 17, 2018, 07:52:14 PM by PrimeTimer » Logged

Husband has ESRD with Type I Diabetes -Insulin Dependent.
I was his carepartner for home hemodialysis using Nxstage December 2013-July 2016.
He went back to doing in-center July 2016.
Michael Murphy
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« Reply #1 on: October 17, 2018, 08:18:22 PM »

This issue annoys me.  My understanding is if any medical provider bills Medicare directly and receives payment directly from Medicare  they have agreed to Medicare rates and cannot charge more to the patients directly.  If they want a larger fee they must bill the patient first and the patient gets reimbursed by Medicare for the covered part of the bill.  I haven’t had to deal with this since my mother passed on 20 years ago. Back then I would call the doctors office and point out the law and if they wanted to sue I would counter sue for slander and libel since they were affecting my mother credit rateing illeagally.  Nerves heard from any doctor or hospital again.
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« Reply #2 on: October 27, 2018, 10:06:04 AM »

Every time I hear of something like that, it makes me glad that I'm Canadian.  Our system is far from perfect, and shortcuts are made EVERYWHERE, but at least I don't have to worry about getting bills for medical services that I have no way of paying.

Dialysis - Feb 1991-Oct 1992
transplant - Oct 1, 1992- Apr 2001
dialysis - April 2001-May 2001
transplant - May 22, 2001- May 2004
dialysis - May 2004-present
PD - May 2004-Dec 2008
HD - Dec 2008-present
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