Best Answer

I would seek legal counsel on this from someone who is familar with medical claims. In the meantime, do you have anything in writing from the hospital showing the agreed upon amounts? It is legal for a hosptial to charge different amounts because doctors and hospitals that are treating pre-authorized insurance patients have entered into an agreement with the insurance company to accept its "fee schedule," which is the preset prices for specific procedures and supplies whereas pre-paid patients have non-covered procedures with no preset fee schedules and agreements with hospitals except on a case-by-case basis. But if you have something in writing proving your agreement with the hospital and its staff for this procedure, they cannot charge you the difference. In fact in the state of Tennessee, medical bills cannot be turned over to collections and cannot "hit" your credit report at all whether good or bad. It is considered a privacy violation to place medical billing information on a credit report. So, in Tennessee, we are protected from vicious billing offices and mob-like collections agencies. We cannot be forced into borrowing money to pay a medical debt either. With this knowledge, it's easier to stand up to harassing collectors. I've actually begged them to take me to court so that I could get the judge to determine that I had suffered enough and have the debt cleared altogether. When they know that I'm not afraid of them, they become much nicer in a hurry.

Also, did you try to pre-authorize this procedure with your insurance? Did they know anything about it and notify you of its policies based on the information provided to them? If they knew of your procedure, but didn't bother to tell you their policies, I would take that to legal counsel. Secondly, was there any information given to them that you had pre-paid? They may be denying because you've pre-paid not because the procedure is non-covered. When I worked for Medicare, a doctor could not bill the patient and then bill Medicare if the patient had pre-paid any amounts above his co-pays. The patient was expected to file a short claim with receipts showing payment because then we could pay the patient directly instead of trusting the doctor to reimburse him.

FILE AN APPEAL with your insurance company. Keep filing an appeal until it reaches an impartial party. All of the insurance companies I've done businss with required an appeal process that included a final appeal to a party that was not employed by the insurance company except as a contractor. By not having face-to-face contact with the insurance company, the contractor could be more objective.

Also each state has a board that regulates its insurance companies. If you feel this company has violated your policy, then file a complaint. If you are unsure, then contact your state's regulatory office and request to speak to someone. They may go a long way in answering your questions about how to resolve this.

Finally, I would definitely speak with an account representative at the hospital. If they seem unfriendly or not knowledgeable about the subject, then don't proceed any further. Many times, however, patients are billed because no one manually adjusted the account to accomodate pre-payment. It may simply be that a computer keeps spitting out this bill because no one has told it to stop sending it to you.

I was a CEO of a health insurance company for years and have faced this question many times. The answer is yes in most States. In fact, in 17 years of experience around the country I never found one State where it was not legal. But that does not mean it is legal in your State. And whether it is legal or not does not mean that it is right. I would check with your State Insurance Commissioner's office and also your State Attorney General's office. (By the way, I left the industy with the attitude that what was once a good industry has become nothing but a greedy enterprise. I wish you the best of luck.)

User Avatar

Wiki User

โˆ™ 2015-07-16 18:31:38
This answer is:
User Avatar
Study guides


22 cards

If you were laid off and apply for insurance coverage on your wife's group policy do you have to answer a medical questionnaire

How many grams of cholesterol should you eat each day to maintain a healthy diet

What would cause a fluttering inside the ear canal

Why is beef fat a solid at room temperature

See all cards
5 Reviews
More answers
User Avatar

Wiki User

โˆ™ 2015-06-05 16:40:59

Yes of course, it is completely legal and it is ethical and is a common sense practice in every doctor or dentists office i've ever been in. The reason your doctor can offer the service for less is that when we self pay, the doctor does not have to deal with mountains of paper work required by the insurer and then wait months upon months to get paid.

All the extra paperwork, the staff needed to complete the insurance forms, make follow up calls and get pre-authorizations, in network out of network and other compliance issues can easily add anywhere from 30 to 100 percent and more to the cost of our care.

It's a matter of overhead and fair value. Less overhead translates to lower cost to the consumer for those services. If the patient is self pay, they likely do not have insurance to cover the vsit anyway so this is a win for both the patient and the doctor. The doctors office is spared the many hours of paperwork and phone calls for your 15 minute visit giving them more time to see other patients and the savings is passed along to this patient.

This answer is:
User Avatar

Add your answer:

Earn +20 pts
Q: Is it legal for a doctor to charge one price if a patient pre-pays and another price if insurance is billed?
Write your answer...
Still have questions?
magnify glass
Related questions

If the primary insurance allows more than the secondary insurance what would the secondary insurance pay?

Secondary insurance will not pay the claim but the remaining charges should not be billed to the member/patient. Provider of service should write off the patient responsibility that primary insurance applied.

What is co-insurance?

Co-insurance is the amount that can be billed to a member or another insurance the member might hold. With medicare, it's the amount that your secondary will get billed and whatever they don't pay you are responsible for. If medicare is your only insurance, that is the amount that you are responsible for.

Is it insurance fraud if a patient seen the nurse practitioner and the medical office billed that the patient seen the doctor?

No, it's not fraud. The Nurse Pratitioner works under the doctors supervision and their visits can be billed out under the doctors name. (I've worked in medical practices for 20 years and this question comes up often).

Offset scenario in medical billing?

Offset- It means adjustments of debts payments to be received against the credit payable. If there is a overpayment made by insurance company to the provider, then the insurance company will adjust by deducting the amount from other patient claim. For example : If the provider billed a patient claim for $250 and the actual allowed is $200, if the insurance paid $250.00 then the excess amount of $50 will be adjusted in another patient claim. Both are correct. Its the process of reversal of old claims and posting the amount to new claim.

If you are at fault for an accident does your insurance company get billed for the damages of the other person in the accident?

Yes,, That's what it's for. It pays for damages you caused to another.

Will you bill my insurance company?

Yes, definitely your insurance company must be billed for all its expenses.

When a secondary health insurance plan does not cover the remaining balance is it the patient responsible?

Gererally speaking, the answer is Yes, after checking to make sure that the claim was billed using the correct diagnosis and codes.

What if you are a us citizen and are hurt in Canada?

you will be treated in a hospital, then your insurance will pay the costs, if you do not have insurance, you will be billed accordingly.

How much does a cholesterol test cost?

my mom said her insurance was billed for $455

What is the importance to the practice regarding the 80 20 payment scheme?

Medicare is paying only 80% of the approved amount the patient is being billed. The responsibility for 20% of the Medicare approved amount will be transferred to the secondary insurance carrier.

What is a Payer of Last resort?

A payer of last resort is an entity that pays after any other primary programs have been billed. For instance, after a primary insurance company, a secondary or even tertiary program can come in and pay the last of a bill. In some cases, the patient can no longer be billed for services after this payer has paid or denied payment.

What is meant by 'accepting assignment of benefits'?

you agree to accept what is allowed by the insurance co You are asking if the insurance company will remit payment directly to the physician's office. Some physician's offices will file your insurance directly and some will not. Those offices that file for you will have the payment sent to them first (assuming that you do not get rejected). After they get paid, you, the patient, will get billed the remaining balance.

People also asked