Must out of network services be disclosed up front?

UPDATED: Sep 30, 2022

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Must out of network services be disclosed up front?

A primary care provider who is contracted with medicare refers a medical patient to a specialist. The specialist takes the medical info from patient and proceeds to treat patient. The patient gets a bill from the specialist and a lab bill from the tests the specialist ordered to pay for everything, saying they do not accept medical Insurance. Why didn’t they tell the patient that at the time they took his info instead of going ahead with exams and lab work and such? My son, the patient in question, assumed when they took his info, and that his primary medical physician refered him to these specialists, that this was covered under medical. We’ve called everyone a number of times and no-one gets back to us or tries to help. What should we do?

Asked on October 13, 2016 under Business Law, California


SJZ, Member, New York Bar / FreeAdvice Contributing Attorney

Answered 6 years ago | Contributor

There is no obligation to affirmatively disclose or volunteer this information "up front." It is up to the patient to manage his insurance and to ask for the information. The health care provider (e.g. doctor) cannot lie about it if asked--but they do not have to tell a patient or prospective patient *unless* the patient inquires. The patient bears the responsibility, and therefore the consequences of not asking.

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