Rules To Know


Top Tip: KNOW THE RULES! (It will save you money and unfair billing!) 

I am assisting a client to deal with a difficult situation, and I thought that this is information that will be beneficial to many people, so it is the topic of today’s blog.

The bottom line: you need to be notified by your health care provider if they are no longer in-network BEFORE your next point of service. They can not bill you the now out-of-network rate if they have not informed you of this change.

Some information regarding the situation:

  • Pediatrician’s office was in-network, and the doctor decided to no longer be in-network
  • They did not have the patient sign any forms or formally notify them of this change
  • The office then charged the out-of-network fee of $960 for 4 visits
  • The client IN FACT ONLY owes $50 per visit ($200) as this was the co-pay on their original in-network insurance rate

Essentially, the provider is going to bill them the full amount because they are now out-of-network, but according to health care insurance rules (legalities), they were required to let their patients know about the change before the next visit and allow the patient and opportunity to choose to pay the higher amount or seek a new pediatricians office that is still in-network. This did not happen, and so my client is able to fight this with the billing department.

The key here is my client was not aware of this rule, but was upset at being billed so much, and thankfully she called me, and I was able to let her know this information so that she can deal with the billing department and get her bill reduced to the fair amount of $200.

My services are free to you as clients (I am paid by insurance companies), and I am passionate about helping people know the rules and helping them navigate the healthcare coverage world to ensure that they are not overbilled. No one should have to overpay for health care.  If you have any questions or need help please feel free to reach out to me.

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