If my doctor didn’t ask for prior approval from my HMO as to whether or not a service was covered and it turns out that it isn’t, do I have to pay for it?

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If my doctor didn’t ask for prior approval from my HMO as to whether or not a service was covered and it turns out that it isn’t, do I have to pay for it?

After an injury, my orthopedist placed a brace on my arm before asking my health insurance provider for approval. When I went to pay for the office visit, he said no payment was due, that it would be taken care of. Later I got a bill for $1400 because my insurance wouldn’t pay for orthopedic devices. When I said I wouldn’t pay for it and told them that they should have asked my insurance first, they revised the bill to $257. I again said that I wasn’t paying for it but I would pay a co-payment of $20. They ignored my letter and every few weeks send me a bill for $257. Am I required to pay this bill?

Asked on January 1, 2012 under Bankruptcy Law, New York

Answers:

FreeAdvice Contributing Attorney / FreeAdvice Contributing Attorney

Answered 9 years ago | Contributor

The real issue is whether or not the brace was actually necessary for the treatment on your arm regardless of whether or not your medical provider would not pay for the brace. Meaning, if you had to have the brace for the recovery of your arm then you should be required to pay the $257.00 claimed due.

If the brace was not needed for the recovery of your arm and the orthopedist went ahead and ordered it for you, then you should not have to pay for it regardless of the insurance coverage issue.

If I were you, I would pay the $257.00 if you actually needed the brace for your recovery.


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