What If My Doctor Doesn't Bill My Insurance Company?

Not all doctors will bill your health insurance company. When providers do not belong to your insurer's provider network or if they choose to participate in a Health Maintenance Organization (HMO), doctors may not bill your insurer. Depending on the type of insurance plan you have, you may pay for services and submit a claim to receive direct reimbursement from your insurance company. It is best to check your provider's network status and billing preferences before seeking care, whenever possible.

Nonparticipating Providers

• Providers that do not participate in a health insurance company's provider network do not always bill insurance companies. They are under no obligation to submit a claim for reimbursement and may seek payment directly from the patient. If your doctor does not participate in your insurance company's provider network, he may choose not to bill your insurer. Before receiving care, ask if the provider wants payment at the appointment or will work out a payment plan with you.

Patient Reimbursement

• If your health insurance plan covers out-of-network services, you may receive reimbursement for any dollars you paid directly to your doctor. If you paid out-of-pocket for services, call your insurer to obtain a claim form and directions for where and how to submit the form. Complete the claim form and send it with your paid doctor's bill to the insurance company. The insurer will send you a check, based on the coinsurance levels for out-of-network services, minus any unmet deductibles.

HMO Providers

• Providers that join HMOs do not bill insurance companies. HMOs utilize a practice called capitation in which they pay a monthly per patient fee to each HMO provider. Providers are paid regardless if they see patients or not. If you are enrolled in an HMO plan, you must select a primary care provider who will coordinate all of your care. You may make a copayment at the time of services but your provider will not need to bill either you or your insurance company for services.

Network Providers

• Participating providers contract with a health insurance company's provider network. Network providers sign a contract agreeing to accept certain fees for services. Most insurers prohibit providers from billing patients for the remainder of the balance, after receiving payment from the insurer. The network provider must accept the insurance company's reimbursement as payment in full, minus any copayments, paid directly by the patient at the time of services.