Can you balance bill the patient if the doctor does not participate with the HMO

[Michele]

Question

In the state of Florida can you balance bill the patient if the doctor does not participate with the HMO? I know you can when the doctor doesn't par with an insurance company but we have run into a big question with HMO's. Aetna told us we cannot bill the patient if it's an HMO plan even though we don't participate with them. Is this true? Thanks
Renee

Answer
Hi Renee
We have run into another provider with this same problem with Aetna. It is our understanding that if you do not have a contract with the insurance company (do not participate) then they cannot dictate to you what you can charge the patient. You must make sure the patient understands that you do not participate with their insurance prior to treating them. This is really a legal question that may vary from state to state.

Perhaps some of the HMO's that are saying you can't balance bill the patient are actually Medicaid products. If they are funded by the state, Medicaid, Family Health Plus, etc, state law does not allow billing the patient. So before treating the patient you need to make sure it is not a Medicaid or state funded policy.
Hope this helps.
Alice

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