Jeffrey M. Liggio
Medical Bill balance billing
Here’s the scenario: You get healthcare, you give the healthcare provider your insurance card (automobile insurance after an accident, or health insurance/HMO otherwise).
The insurance company/HMO pays the provider what it wants to pay (that determination is another subject completely!)
Now you get a bill from the healthcare provider or a bill collector telling you what you owe.
Should you pay the balance? Should you pay less than the balance? Should you ignore it?
The first thing you should do is to look at your policy. Do you have a deductible? Do you have a co-pay? Is there an out-of-pocket limit?
If you do, have you met your deductible and reached your out-of-pocket limit? If you’re not sure, contact your insurer/HMO and ask them.
Second, was the provider a network provider of your insurance company/HMO? Again, your policy may preclude the provider, who has its own contract with your insurer/HMO from balance billing you, at least for any amounts in excess of your deductible or co-pay.
Third, there may be statutes or regulations in the state where you live of received the care that specifically prevent the health care provider from balance billing you. (You don’t really think that the healthcare provider or collection agency looks at the statutes or regulations before sending you a bill, do you??)
On that point, at least in Florida there are several statutes that specifically limit or totally preclude the healthcare provider from balance billing you. Here are links to the Florida Statutes:
For Health Insurance, Florida Statute 627.6471: http://www.flsenate.gov/Laws/Statutes/2015/627.6471
For an HMO: Florida Statute 641.3154: http://www.flsenate.gov/Laws/Statutes/2015/641.3154
For motor vehicle PIP/No-fault insurance: Florida Statute 627.736(5): http://www.flsenate.gov/Laws/Statutes/2015/627.736
Sometimes even all the steps above might not help though….
Our client, Ms. Green was injured in an automobile accident. Her PIP/no-fault insurer was State Farm. She sought medical care, and her providers submitted their bills to State Farm. Despite the requirement that State Farm must provide notice in its policy that it would pay the providers according to the 200% of Medicare fee schedule it did not do so. Florida Statute 627.736(5) also was to protect her, because it mandates that if the provider accepts the 200% of Medicare payment, it could not balance bill her.
State Farm paid 200% of Medicare, but never informed her in her policy, her provider balance billed her, and she she paid the balance that she should never have been billed for in the first place.