Billing Tip: Can the doctor bill me?

[Steve Verno]

I see this posted on forums, in messages and in emails:

I went to see Dr. Detroit.  I received an EOB from my insurance ABC Insurance.  The EOB says all I owe is $15.00, but Dr. Detroit is billing me for $165.00.  Do I owe the $15, $165.00 or do I pay nothing which is what ABC told me when I called them?

While this is a good question, providing a definitive answer is not possible due to missing information.  First we don’t know who this person really is and we don’t have access to information that is unknown.  We don’t know if this person is telling us the truth, the whole truth and nothing but the truth.

We don’t know if the information on this unknown EOB is true and factual.  We haven’t looked at the EOB.  There may be more information that has been withheld.  The information on the EOB may not be favorable to the patient or it may say something different than what we have been told

We don’t know if Dr. Detroit is contracted with ABC Insurance.  If Dr. Detroit is contracted, we haven’t seen the contract, so we don’t know the payment terms.  We don’t know any other allowed or disallowed clauses.  The service may have been denied as a non-covered service with the patient owing the $165 as a non covered service.  We also don’t know if the service that was billed was actually provided and properly documented.  The patient may have been seen for an ingrown toenail but the doctor may have billed for the ingrown removal, a level 5 consultation and a level 5 office visit. 

We don’t know the patient’s contract with their insurance company.  Dr. Detroit may be non-par with ABC and if so, the patients’ contract may say that if they go out of network, they wont pay any claim.  It may also say that all they have to pay is $X of ABCs internal payment allowance. For example, it may say all ABC has to pay is 40% of their established allowed amount and it may say that the patient pays the balance up to the amount of the submitted charges. It may also say that it is supposed to pay 100% of charges.  The patient’s contract may only allow a limited number of visits for a specified service.  It may also allow only $x on a service and if the patient exceeds this amount, the patient pays the excess. 

Medical Billing is completely different and complex.  There are so many outside influences that giving an answer without knowing the whole story can be dangerous.  Can the doctor bill me for the amount on the bill?  Not knowing everything, there is no yes or no answer.