Balance Billing

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Regular Member

Date Joined Sep 2005
Total Posts : 89
   Posted 12/18/2008 8:37 PM (GMT -7)   
Balance billing is when the provider submits a bill to insurance, e.g., ($60), insurance pays a portion ($48), and then the provider bills for the remainder ($12) to the patient. 
I know Medicare prohibits this--they must accept amount the government allows, but what I'm wondering about is private insurance, specifically in Pennsylvania.  I just had surgery and almost all the insurance payments were accepted.  Example, the hospital bill was $79,000 and they accepted $63,000.
The top example is what happens when I go to my gastroenterologist for an OV.  Visits before a surgery or procedure such as a colonoscopy are covered and insurance pays for it assuming I've met my deductible, but other routine checkups are denied by my insurance and I am billed the higher amount.  This gripes me. 
Anybody have a knowlege on this subject?

Veteran Member

Date Joined May 2005
Total Posts : 4219
   Posted 12/18/2008 8:44 PM (GMT -7)   
Yes. It depends on the contract with the provider. In a PPO if you go to an in-network provder the doctors can not balance bill. If you go to an out of network provider they may. I am guessing in an HMO they can not balance bill. If you get a bill you can either call your insurance carrier or your health care provider and ask why you are being billed. More often than not it is a mistake and your bill was supposed to be written off.
27 Year old married female law student (last year!!). Diagnosed w/ CD 4 years ago, IBS for over 10 years before that, which was probably the CD. I am sort of lactose intollerant too but can handle anything cultured and do well w/ lactose pills and lactaid. For crohns I am currently on Pentasa 4 pills/4x day and hysociamine prn. I also have bad acid reflux and have been on PPI's since age 13. I have been through prilosec, prevacid, and nexium. Currently I am on Protonix in the morning and Zantac at night. I also take a birth control pill to allow some fun in my life.

Veteran Member

Date Joined Jan 2005
Total Posts : 1823
   Posted 12/19/2008 4:21 AM (GMT -7)   
You need to check into the specifics of your plan. I'm in PA too but my insurance is through DH and is completely different from what I can get through my employer -- both are BCBS. With my DH insurance we are balance billed but it depends on the doctor actually. Our primary and my GI(UPMC) balance bill for the difference of allowed and paid amounts. But my DH's endo doesn't bill us for any difference. It depends on your dr contract with the carrier.

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