Paying the balance on medicals bills billed to insurance?

My Mom was asking me about this but I don't know anything about it so maybe you can help me. She was asking me about my brother who is stuck with a bunch of bills for a necessary operation he had on his leg. The hospital billed the insurance but they only payed part of some of the bills. What she was saying was that the hospitals were supposed to accept what the insurance payed and not expect the client to pay the balance. That doesn't sound right to me but I don't know anything about medical billing. Does anyone have any knowledge of this? Thanks for your help.

If your brother used a hospital and doctors who are contracted and in the network of the insurance company, they will accept a lower rate (already negotiated in the contract) from the insurance company. Insurance policies usually have two payable rates; in-network (provider) rates, and out-of-network rates. First your brother must pay his deductible (the first bills), then he pays the agreed percentage of the following bills until he reaches his "out-of-pocket maximum. If you use an in-network provider, the insurance company pays the higher percentage. Example: $1,000 deductible (he pays the first $1,000 in bills) $3,000 out of pocket 80% in network (he pays 20% of the next $15,000 at which point that equals $3,000). Feel free to call or email our office for a casual conversation to get your questions answered. www.thepolicyconnection.com karen@thepolicyconnection.com

Well, if your brother's policy has a deductible or coinsurance, he is liable for those amounts. (Coinsurance = the percentage that you're liable for. ex. 80-20 coverage, the insurer pays 80% of allowed amounts, you pay 20%.)

I'm not surprised that he received bills - its rare for a person to have a policy these days that covers at 100% with no deductible or out of pocket expense.

Here's what your mom is thinking of:
If your brother had services done at a network hospital, the hospital is required to accept the insurer's discount. But your brother is still liable for his deductibles/coinsurance/non-covered expenses.

Ex - (For sake of explanation, let's assume 80-20 coverage, no deductible or out of pocket max.) The hospital bills $15K. The insurance company says that the standard rate for the services is $10K. With the 80-20 example, the insurer would pay $8K, your brother would pay $2K, and the hospital would write off the $5K. The hospital would have to accept the $5K discount from their bill, but your brother would still be liable for his 20% (the $2K = 20% of $10K).

Not true. Most plans have a "coinsurance" where you're still responsible for a percentage of the bills - usually 20%.

Your brother needs to call the number on his insurance card, see what his coinsurance amount is, and look at the explanation of benefits statements to see if it looks right.

The quick answer that this depends on two things:

1. Everyone who had a part in the surgery (doctors, hospital, anesthsia, etc.) was contracted with his insurance company.

2. He paid his copay already. If he has a deductible or a plan where his insurance pays a percentage, then he has to pay his percentage.