Question:
Has any1 had to pay the difference btwn what the ins. pays & what the doctor charges?
I have Cigna POS. I chose an in-network doctor that does surgery at an in-network hospital. The doc's office says they don't have a contract to perform bariatric surgery, though they do have a contract to perform other types of surgery for Cigna. Anyway, Cigna is only paying the "contract" amount and the doctors office is balance billing me for $3,558. I have called Cigna several times and they say the doc can't balance bill me, but the doc's office says they sent Cigna a letter and told them they were going to and got no reply. I haven't seen anyone else on this website that has mentioned, once they were approved, having to pay out-of-pocket. Any insurance experts out there that can offer some advice? Thank you. — Angie C. (posted on October 15, 1999)
October 15, 1999
Hi Angie.
I used to do medical billing, and if our doctor participated with the
patients insurance, we could not bill for the difference. It is in their
contract with that insurance company. The surgeon who did my WLS, was not
in my network, so I had to pay him $5500, upfront and wait for the
insurance to reimburse me. After I got the reimbursement check from my
insurance company, I understood why the doctor did not participate, I only
got $600 back.
— Tammy S.
October 15, 1999
I was told that he charged 4800 to do the surgery and had to give them
$1000. If my insurance pays more than $3800, they will refund me the
difference. Ususal and customary is what the ins. co. will pay and that
varies company to company.
— Diane N.
October 15, 1999
You need to contact the Contract/credentialing department of your insurance
company! I believe that your doctor either has a contract or doesn't, I've
never heard of a provider contract that allowed the physician to exclude
certain procedures. I could be wrong, but it doesn't sound right to me. The
credentialing coordinator with your insurance company can easily pull the
signed agreement to determine this. If an in-network provider balance bills
patients then he/she is in violation of the agreement with the
payor/insurance company. I certainly don't consider myself an
"insurance expert" but I was a Senior Benefit Analyst for CIGNA
for three years and I've spent the last ten years managing the billings and
insurance contracts for a medical group. I hope that this info will help a
little.
— Morgan B.
October 16, 1999
Hi Angie, I had Employers Health, a PPOM insurance and no one told me there
would be a balance, so when I got a bill for $1,800.00 I wasn't happy. But
when I considered that they paid more than $35,000.00 I felt better. I am 9
mos. post op and am very thankful for the surgery. Sandi V.
— Sandi V.
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