AboutTricia Expertise Has your medical insurance company denied your claim and refuses to pay? Have
you received a pre-authorization and still your insurance company
refuses to pay? How can you get your insurance company to reverse a
denied claim? How do you get a provider to waive your copayment if you
are financially unable to pay? Can a provider sue you for a unpaid bill and
will they? Can a provider send me to a collection agency for a medical bill?
If my insurance company does not pay, am I responsible? If you have these questions or others on why your insurance company is not paying your bills, I can help. I can give you "tricks of the trade" to get your insurance company to pay.
I have limited knowledge on Medicare and Medicaid and that is not my expertise. Each state is very different regarding Medicare and Medicaid so you need to review their website when you have questions. So please no Medicare or Medicaid questions!!
Experience In the medical field for over 20 years spending majority of time in the collections aspect.
Question If is a claim denied, would I have to pay "list price" of a procedure or the insurance company's negotiated rate?
For example, if a procedure costs $10K and the insurers negotiated rate is $5K, would I pay $10K or $5K?
Is there a clear standard for how this works?
Answer Hi Spencer!
It depends-------your Explanation of Benefits that showed that your claim was denied will show you what amount you are responsible for. Look under "patient liability". If it does not show on your EOB, then call your insurance company and ask.
If the provider billed your insurance company a negotiated rate than that is the only amount they can bill you if you carrier denies........they have to charge you what they charged the insurance company.
If they billed your insurance company their UCR (usual and customary rate) but would accept a negotiated rate if your insurance company paid, then they can charge you the higher amount.
