They ... put the allowed amount of $1,365.27 to the patient's deductible. ... they have 70% out of network benefits, so my provider expects $10,570 from UHC.
Quote from: PippiT on December 29, 2015, 02:39:48 PMAn ethical out-of-network provider will make certain the patient fully understands exactly what dollar amount s/he could be responsible for - for the services to be provided - before they are provided. In this case, it sounds like the patient is responsible for the full charge (being out-of-network, your client is under no obligation to accept only 70% of what the patient's carrier will pay).An out-of-network provider can charge their patients whatever they want to charge. Collecting that money is another matter entirely. Word-of-mouth can destroy a provider's reputation. So your client needs to proceed carefully here.I completely agree with this. I have no idea what the doctor and the patient discuss, but I know to check with my insurance prior to any major surgery to see what kind of expenses I am responsible. What I don't understand is why do these out of network surgeries at the ASC when they should be done at the hospital. I'm not in his head so I can only surmise he has an unrealistic idea of how he should be paid. The bottom line to him is that he does not have a contract and the billed amount is the allowed amount and that the insurance company needs to pay it. I've told him it is patient's responsibility per the ins. company and he says that is unacceptable. I feel like I've wasted a lot of time on these 4 claims.
An ethical out-of-network provider will make certain the patient fully understands exactly what dollar amount s/he could be responsible for - for the services to be provided - before they are provided. In this case, it sounds like the patient is responsible for the full charge (being out-of-network, your client is under no obligation to accept only 70% of what the patient's carrier will pay).An out-of-network provider can charge their patients whatever they want to charge. Collecting that money is another matter entirely. Word-of-mouth can destroy a provider's reputation. So your client needs to proceed carefully here.
I have to put my 2 cents in on this. If the proof of past full payments cannot be produced, this is a RED FLAG and I do not believe this true unless their is some unethical practices going on. Is this provider choosing to be out of network with all insurances or just these couple? Do you call insurance companies prior to services to get the out of network benefits? With out of network companies, you have the right to have the patient to pay for services prior to the service. You can then file the insurance and based on EOB, you may have to refund some moneys but at least you have your money up front.The way I am understanding how this provider is, he/she has ABSOLUTELY no clue of what he/she is talking about. My advise to you is to have a notebook and document EVERYTHING you do and what the provider says and does, (no patient information of course). You could be liable for anything that comes down the line from your lady prior to you. Also, if providers that are out of network, got insurance payments in full, there would be no reason to have in network benefits/out of network benefits. Common Sense people.
He won't let me appeal. I just have to keep running in circles.