Can A Doctor Really Demand An Extra $75 Upfront?

Insurers prohibit doctors from charging more than a copayment or other amount specified in your plan.

hide captionInsurers prohibit doctors from charging more than a copayment or other amount specified in your plan.


Douglas W Allen/iStockphoto

This week, I answer readers’ questions about what doctors can ask for in advance and the nuances of switching insurance plans, both on and off the health exchanges.

Q. After signing up for a gold level plan on the health insurance marketplace, my physician, who is part of my plan, asked for $75 up front. My copayment is $25. His office also wants to keep a credit card on file. Is this legal?

A. Probably not. The contracts that physicians sign with insurers in order to be included in a plan’s provider network include “hold harmless” provisions that prohibit doctors from charging members more than a copayment or other specified cost-sharing amount for services that are covered. In addition, many states have laws prohibiting providers from “balance billing” health plan members for amounts over what the insurer paid on a claim.

It doesn’t matter where you buy your coverage; the same rules apply. “To the extent that there are state restrictions or contracts, they’re the same in qualified health plans on the marketplaces and other plans,” says Sabrina Corlette, project director at Georgetown University’s Center on Health Insurance Reforms.

Filling out the forms is part of the ritual of going to the doctor. But with the Affordable Care Act, it's more complicated.

Article source: http://www.npr.org/blogs/health/2014/02/25/282447840/can-a-doctor-really-can-demand-an-extra-75-up-front?ft=1&f=131849999

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