HMO? Balance Billing a No-No
A recent opinion, dated April 13, 2009, issued by the NYS Department of
Insurance answers the often asked question of whether a practitioner may
balance bill for amounts in excess of the amount allowed by an HMO.
Unfortunately, the answer hasn't changed and remains to be NO. The DOI
explains that an HMO must hold its subscriber harmless from charges in
excess of any contractual co-payment amounts, and therefore, balance billing
is prohibited. This answer is rooted in contract law, which stands that if
you agree to something in writing, that agreement will prevail. Subscribers
have contracts with their HMO and participating providers have contracts
with the HMO's they participate with. In almost all instances, those
contracts (specifically those with HMOs) explicitly cover balance billing.
So, if you want to know whether you fall under this category, you must read
your participating provider contract carefully.
Additionally, the opinion does reiterate that as there are no statutory
provisions governing balance billing by practitioners where an insurer other
than an HMO is involved. However, contracts between insurers and
participating practitioners may prohibit balance billing.
The above information is for education and discussion purposes only.
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