HMOs and not paying your doctor

[Anonymous]

My husband, who is a lawyer, told me that if you have an HMO you do not have to pay your doctor's fees anything past what the HMO would pay. He had to get back to work so I couldn't ask him to elaborate or ask how he would know (since he is a lawyer and not a doctor).
Is this true? You can see anyone you want but don't have to pay them? When I worked as a nurse at Suburban, I remember a very well-off gentleman yelling at the hospital staff about how well-connected he is, how he better receive the "best" treatment for his brat of a teenage. I remember seeing that he had an HMO. Will this A$$hole get away with not paying his doctors?
TIA for the info.

[Anonymous]

Think it may depend on your coverage. And if it's in network and for an approved procedure or treatment.

[Anonymous]

Usually an in-network doctor can't bill you more than the agreed-upon price for a particular procedure or visit. So I think that's true if it's a doctor that's in-network.

Out of network, there's no advance agreement and they can bill you whatever they want.

[Anonymous]

in network doctors cannot bill you beyond their pre-arranged fees.
out of network doctors can bill you whatever they want to and have every right to come after you in court for the bill once you agree to the service.

[Anonymous]

In Maryland, a provider cannot "balance bill" a patient for the remainder of the bill not paid by the HMO. This applies only to covered services. However, it applies to participating as well as non-participating providers. So if your HMO covers a colonoscopy, a participating provider has to accept the reimbursement amount specified in the contract between provider and HMO and cannot bill you for the remainder. If you get the colonoscopy done by a non-participating provider, the provider has some restrictions placed on how much s/he can bill you, which is specified in statute.

A patient can never be balanced bill for hospitalization or emergency care.

A patient can be fully billed if it is a non-covered service, like plastic surgery.

This is covered in the Maryland Health - General Article, not Insurance law, because it applies to HMOs. Maryland is different from most states in this regard.

[Anonymous]

There is some truth to this. We use an HMO and we kept getting a bill from a doctor beyond our copay. It wasn't huge, like maybe $50, but we thought it was strange because we had already paid the copay and that should be that. When we called the insurance company to find out what was up, they told us to absolutely not pay it, and then the bill stopped showing up and we never heard another word.

[Anonymous]

Right, if it's in-network, the provider is contractually obligated to provide the service (if a covered service) at the negotiated rate. They can't bill the excess, it's a violation of their contract with the insurance company.