My son had emergency surgery and his insurance paid the surgeon the physician provider fee because the surgeon (who is not a provider in our HMO) was on-call for a provider physician according to the Tax ID on the physician's claim to the HMO. The physician is billing my son $700, the difference between the provider and non-provider fee. I've complained to my HMO who state that I am not obligated to pay this bill, but the physican continues to bill me. What recourse do I have to resolve this dispute?

Good afternoon... Your son has fallen into a fairly common claim situation when emergencies come up and how a PPO/HMO processes a claim.

1) Does your HMO have language in the policy that will provide network benefits in an emergency or non-elective scenario? Some plans will provide reimbursement to specialists when an option to select your care is not available.

A lot of PPO or HMO plans have trouble recruiting pathologists, anesthesologists, radiologists, and emergency room physicians to their networks so many plans will provide network level payment in emergency situations.

2) Since the HMO has already processed and paid the provider, the next step will be to ask the provider if he/she is willing to accept the reimbursement that has been provided. It sounds simplistic, but most insureds, myself included, do not think to question or ask the provider if another option is available.

If you explain the situation with your HMO and that there was not an intent to go outside the network, the physician may relent and not look to collect the additional $700.

3) Is there an independent agent who is working with your son's policy - either an individaul or group plan? If there is, I would reach out to that individual and ask their advice as well with the HMO plan your son has. The agent may have dealt with this exact scenario and could also be able to offer advice and act as an ally. The agent is earning fees or commissions for their expertise and will want to do what they can to keep the customer happy.

I am concerned that the HMO is stating you are not obligated to pay the additional fees. Did they provide a reason? If they have a reason, it may circle back to my first point about contract language and how the HMO processes benefits for non-network charges. That could be very useful in negotiating with the physician.

The provider has a right to charge the fees that they did and are not obligated to accept only what the carrier reimburses, but I think they most are reasonable and willing to further discuss your specific situation. More than likely, this is not the first time this physician has run into a claim scenario like this.