Linda Brandwin, R.N. Linda Brandwin is a registered nurse and a medical billing and claims specialist. For the past 10 years she has worked directly with insurance companies to give advice and guidance to the health care consumer. Readers may send email or write Linda Brandwin at 5500 Single Oak Hill Ct., Woodbridge, VA 22192.

Can healthcare providers charge balance?
Oct. 10, 2003

Q: When a medical biller submits a bill to my insurance company, the insurance company has a maximum "allowable" amount they will pay for each service. I have gotten used to the healthcare provider writing off the difference. I have not been charged for this balance in the past.

This seems to have changed recently. I had surgery about five months ago. All medical bills were submitted to my insurance company and they paid the allowed amount to the healthcare providers. I am now being billed for the difference between what the original amount of the claim was and what the insurance company allowed. My insurance company told me there is no clause in my contract to keep the billers from charging me this balance.

Is it legal for my healthcare providers to charge me this balance? Do I have to pay? Is there a way to get the billers to reduce or write off the balances?

I have already met my out-of-pocket maximum for the year for my in-network and out-of-network visits. This is turning out to be several hundred dollars over and above my out-of-pocket maximum for the year.

A: If the doctors or the hospitals are providers of your insurance company, you may not be billed the difference between the amount of the claim and what the insurance company allows. This is a provider discount or the disallowed and is written off. The contract between the insurance company and your provider states that the provider will accept the allowed amounts as his fee.

If the doctor is not a provider of your insurance company, he is entitled to bill you and collect from you the full amount of the claim. Insurance companies have their own policies for handling out-of-network claims. It appears that your insurance company pays on the allowed fee and you are responsible for the remainder of the bill. When you say you have met your out-of-pocket maximum for out-of-network claims, I do not think that covers the portion of the bill that is above the allowed amount. You are still responsible for that amount. Check with a supervisor at your insurance company to confirm what is included in your out-of-pocket maximum.

There is only one way to get your bill reduced; you will have to ask. But, remember, the healthcare provider is under no obligation whatsoever to reduce his bill. Perhaps, if this is a hardship then the billing office may be able to work out a payment plan with you.