The Growing Problem Of Balance Billing With Doctors


You go to the hospital for an approved procedure and expect for your insurance company to pay the bills and you pay the co-pay or deductible. But what about the doctor in the operating room that is “out of plan” or not a part of the Blue Cross Blue Shield plan? She may only be paid 50 cents on the dollar and guess who the doctor tries to stick the other 50% to? Yep. You. Welcome to the wild world of “balance billing”.

Maria Perotin recently wrote an informative article about this practice which we recommend you read. Detailing one man’s experience, Maria writes:

As Heidelberger remembers it, no one discussed his insurer’s network in 2007, when he underwent his medical procedure.

An anesthesiologist at the hospital spent a few minutes giving him a local anesthetic, he said.

Then, his physician tinkered successfully with a device that previously had been implanted in his heart.

Months later, the anesthesiologist’s bill arrived for $1,005.

That’s when Heidelberger discovered that the doctor didn’t have a contract with his PPO.

The anesthesiologist had set a fee of $2,020 for his services, and the insurer had paid only the amount it deemed fair for an out-of-network doctor – $1,015. So, the doctor turned to Heidelberger in October for the remainder of the bill.

Heidelberger has refused to pay.

He said he believes that the bill is too high and took too long to arrive.

And he contends that he should have been warned that the anesthesiologist was a costly out-of-network provider.

“My strong belief is this: If I take my car to a garage or you take your car to a garage, because the engine is acting peculiarly, the garage calls you and says: ‘The engine’s wrong. This is wrong. It’ll cost you thus-and-such to repair it,’ ” Heidelberger said. “I think I should’ve been made aware of that and had the option to choose another anesthesiologist.”

Be aware of this practice as these bills can quickly be turned over to collection agencies. It has been our position for years that contract law applies to medical bills. If the term of “price” is not agreed to ahead of time, then the law will supply a reasonable price term. If we want to know what is reasonable, we look to the “usual, customary, and reasonable” (UCR) that insurers such as BCBS set forth. We have always had hospitals and doctors back down when challenged as they may try and collect in balance billing or from an uninsured person two to three times what the UCR is which is not reasonable.

We’ll keep an eye on developments in this area and keep you posted.

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