Oneida, NY asked in Health Care Law, Insurance Bad Faith, Insurance Defense and Civil Rights for New York

Q: Can a health care provider accept insurance based on merit of the patient?

A dentist office accepts my current insurance. But make me pay full price, bills my insurance separately then sends me a check for less than 50% of what I payed when my insurance covers 80% of the total visit. They also only make some people who have the same insurance pay. So if you and I both had the same insurance coverage, if they liked you, you would only pay your 20% copay, and I would have to pay 100% upfront and wait for a check later. Is this discrimination? Is this legal? Can they pick and choose based on merit who they will bill insurance for and who they won’t?

1 Lawyer Answer
Tim Akpinar
Tim Akpinar
  • Insurance Claims Lawyer
  • Little Neck, NY
  • Licensed in New York

A: It could be difficult to speculate why a dental or medical office would apply different billing protocols. As a convenience to the patient, some offices do not bill patients but instead, have them complete paperwork enabling their billing staff or contractor to bill on patient's behalf. When procedures are denied, it can sometimes become complicated as to what the medical provider can pursue from patient, depending on the nature of the denial (not medically necessary, maximum benefits reached, duplicative services, exceeds fee schedule, improper coding, etc.). Some types of denials preclude recovery from patient Without seeing the file, this could be difficult to get a response to - one option is to check with your insurance carrier if your billing is in compliance with their guidelines. Good luck

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