What are the laws regarding the amount of coinsurance thata healthcare provider can bill the patient if there are primary and secondary insurance?

I understand the coordination of benefit laws regarding the secondary insurance having to pay the balance up to 100% of the “highest allowable costs”. My question has to do with healthcare provider using this law intended for insurance providers to bill the patient for the highest coinsurance of the 2 plans. Does the coordination of benefits law apply to the healthcare provider when determining the balance due?

Asked on October 24, 2011 under Insurance Law, Washington


MD, Member, California Bar / FreeAdvice Contributing Attorney

Answered 9 years ago | Contributor

This actually may be a loophole and usually what occurs is the patient together with the provider need to check with both insurance companies to determine a) who is the primary provider and b) who will pay what percentage of benefits. Physicians may often use this game to then bill as high as possible but understand you also have the right to question the amounts billed, even if the insurance company is paying the 100% cost. This occurred during a scam not too many months ago wherein people were being swabbed for donor matching and the insurance was being billed in the thousands instead of hundreds.

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