Contract question: How much can a physician legally charge for services over and above the amount paid by a patient's health insurance carrier?
Answer: Not as much as a physician might like to charge. Yet, probably more than an insured patient would like to pay.
That is the situation confronting a USD Senior Legal Helpline caller who visited a physician who markets pain-relief therapy. After three sessions, and no relief, the caller terminated the patient-physician relationship.
He is insured. "I have an insurance policy that pays 100 percent of ?usual and customary' charges," said the caller. But now I have received a collection letter from the physician demanding that I pay $5,400 over and above what my insurance has paid."
He said lawyers representing his insurance carrier had informed the physician his fees are substantially above acceptable "usual and customary" levels, and the carrier refused to pay the amounts demanded. "Do I have to pay?" asked the caller. "What should I do? Am I left holding the bag?"
The caller is caught between two contracts with competing financial incentives: The first is a contract with a physician who wishes to maximize receipts for the sale of his pain-relief services. He asserts his charges are appropriate.
The second is a contract with an insurance carrier that maximizes its profits by paying less than the amounts demanded by the physician. The carrier asserts the physician's charges are excessive.
I advised the caller to not pay the bill until I receive a response to a letter I sent to the physician, advising that the caller had not agreed to pay whatever amount the physician chose to charge, but rather a "commercially reasonable" amount. I will send a copy of the letter to the insurance carrier, reminding it of its contractual obligation to pay 100 percent of "usual and customary" fees.
In the meantime the caller will seek alternative therapy for his pain, now aggravated by the financial pain being inflicted by his former pain doctor.
(Pro bono legal information and advice is available to persons 55 and older at the USD Senior Legal Helpline, 1-800-747-1895; email@example.com).