Sample Letter Regarding Balance Billing

*Practice Tip*

Doctors really don't have the energy to fight this battle. And they are on the wrong side of it. You just need to state your position aggressively while pointing out, if it is true, that the care received was fantastic. You need to put everything in writing when you are dealing with balance billing (or anything else when dealing with health care providers. Organizationally, many of them are an utter mess. Make sure you make your position clear in a written document.

Via Fax: 410-888-9286
John Mitchell, Office Manager
Barksdale Medical Group
10393 Windstream Drive, Suite 400
Columbia, Maryland 21045

Our Client: Michelle Marin
Date of Loss: August 27, 2013
Your File: 53-87351.353

Dear Mr. Mitchell:

It was a pleasure to speak with you today. I want to make crystal clear our position in writing.

As we discussed, I represent Michelle Marin for life threatening injuries she has suffered in August, 2013. She has received care - excellent care in fact - at your office over the last few months.

The accident has put a financial burden on Ms. Marin. In addition to her PIP benefits, of which I think you were a beneficiary, Ms. Marin also has health care benefits through CareFirst Blue Cross. Under that plan, doctors like you are to be paid in accordance with the plan’s pre-negotiated service rates. The terms of the plan call for CareFirst to remit 80% of the pre-negotiated service charge to the health care provider, with the policy holder/patient remitting the remaining 20%. You made clear your office participates with CareFirst.

Ms. Marin has advised that you intend to balance bill her for the fine services you have rendered. In other words, you wan to both accept payment of the pre-negotiated service payments under her insurance plan, and then try to get the rest from her personally. You told her - and me this morning - that this was your practice in personal injury cases.

I believe pretty strongly that you cannot “balance bill” her for the difference between the pre-negotiated rates and the regular retail services you charge. I've looked at the policy manual issued by CareFirst outlining her rights and obligations under the plan. I have reviewed it in detail and see no exception to the basic 80/20 payment arrangement existing between CareFirst and its policy holders. Specifically, I see no provision in the manual that allows for the imposition of different billing rates by the provider in cases of third party injury. To “balance bill” the patient for sums above the rates the office has agreed to accept from CareFirst imposes a much higher payment obligation on the policy holder beyond the 20% contemplated under the plan.

After our call, I believe we can work all of this out but this is very important to Ms. Marin for obvious reasons. If you have any evidence that contradicts what I have said her, please let me know immediately. Otherwise, could you be kind enough to let me know that you will not attempt to balance bill her for the services you have rendered.

Very truly yours,
Ronald V. Miller, Jr.


Questions and Answers

Question: What is balanced billing?

Answer: Balance billing is when the health care provided tries to get payment from you for the entire bill when only some portion of the medical bill was not covered by insurance. So the doctor goes after the patient for the remaining balance.

Question: Can doctors balance bill?

Answer: Doctors generally cannot balance bill Medicare or an HMO in Maryland. The Maryland General Assembly passed balance billing legislation over 20 years ago to protect HMO participants from health care providers with their hand out for the entire bill. So, inMaryland, in-network and out-of-network providers are prohibited from balance billing an HMO enrollee for a “covered service" (i.e, a service authorized under the health insurance agreement). Generally speaking, emergency department care of out-of-area urgent care are going to be considered to be covered services.

Question: I don't have an HMO or Medicare? Can my health insurer balance bill?

Answer: The answer is complicated. Maryland has complicated statutory scheme that covers balance billing. Out-of-network providers can balance-bill patients. But the amount of the medical bills that can be reimbursed is limited limited what has not been paid up to the Health Services Cost Review Commission-approved hospital rate.

Question: Does balance billing mean no co-pays or deductibles?

Answer: Balance billing does not include deductibles, copayments, or co-insurance that may be mandated by your health insurance plan.

Question: Why do doctors try to balance bill?

Answer: Money. Pure and simple. Medical practices these days often have thin profit margins. The doctors are looking for ways to recover as much money as possible. This violates the Maryland Consumer Protection Act in many cases and the office of the Attorney General has successful brought claims against physician groups that have balanced billed in violation of Maryland law.

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