Can a medical practitioner legally charge health insurances a different amount from what it would charge a non-insured patient? In the United States, can a medical practitioner legally charge health insurances a different amount from what it would charge a non-insured patient? I am mostly interested in the states of California, Florida, and Massachusetts.
They're not actually billing people different amounts because they have insurance or not. Doctors can pretty much bill a patient whatever they want for their service, similar to how a grocery store can charge whatever they want for their fresh deli cheese. Generally, they charge every single person the same amount. It just gets discounted depending on the insurance you have and how much they're willing to pay. One of the huge benefits of having medical insurance (outside of them paying for your medical expenses) is that they build contracts with service providers, known as their network. Those contracts specify prices (both preset and algorithmic) for certain services that you receive through those providers - the insurance provider will only pay that much and the doctor cannot charge the patient more than what is paid. If a claim was processed through a different insurance provider, the price will likely be different since each provider will have a separately negotiated contract with different price points for different services. It's not a system of "this is the insured price and this is the uninsured price" but rather a system of "this is the contract you established saying you'd accept this much from us for this service." For an uninsured person, though, you have no insurance provider and more importantly no provider contract backing you up. So you'd have to face the full force of the non-discounted price of those services. You'll face the same problem even with insurance if you go out-of-network, where the provider does not have contracts and therefore will only cover up to a certain amount that they would normally pay out for a similar service, requiring you to cover the rest of the amount of whatever the doctor decided to bill for that particular service. Without that insurance contract preventing the doctor from billing you the remainder of what they'd normally charge, you'll likely be slapped with a bill for that remainder. Directing back at your original question: there is no reason that a medical provider would ever legitimately bill someone a different amount because they are insured or not, thus there are no laws preventing it. It's that they already agreed to accept this certain amount from patients covered under this specific insurance. Again, they bill every patient the same amount - the insurance company is just saying "we're giving you this much and the rest of this, yeah that needs to go away." If you've ever looked at an EOB (Explanation of Benefits) from your insurance company, you'll see that the actual billed amount from the doctor is almost always much, much higher than what is actually paid out by you or the insurance, often known as the insurance discount. Maybe you'd rather think of it as a coupon?
I think it really is a state-by-state answer. From a web site for doctors getting involved in Telemedicine. Some medical boards such as Alabama, Montana and Oregon offer a special purpose telemedicine license. Other states that regulate telepractice in medicine include Texas, Florida, California and Colorado. The levels of regulation vary greatly by state. For example, California and Florida, similar to New York, require full licensure to perform any function relating to patient care, with some exceptions for consultation in some instances. Other states are exploring the issue of telepractice and in general, how to regulate it. That site has a state-by-state break out of the rules. I see other things about reciprocity among some nearby states. Three states (MD, NY, VA) and Washington DC provide reciprocity to bordering states. Alabama and Pennsylvania have agreements with other states to grant licenses to out-of-state physicians who have licenses in states that reciprocally accept their home state licenses. In Connecticut, an out-of-state physician can obtain an in-state license based on his or her home state standards.
Employees of an employer aren't governed by a fault based liability regime in the United States (subject to some usually quite narrow exceptions that vary from state to state, which sometimes also limit tort liability). Instead, employers are required to have worker's compensation insurance policies in place, in exchange for not having any tort liability whatsoever to employees. (An employer who doesn't have worker's compensation in place is strictly liable to the worker for all injuries suffered by an employee whatsoever at work, without the prohibition of a worker's compensation insurance policy plan on paying things like pain and suffering damages as well.) Worker's compensation insurance provides coverage (in principle) for all medical costs incurred, all lost wages, and in the event of a death support for dependents if any and a modest death benefit sufficient to provide a funeral if there are no dependents. Often, in practice, worker's compensation insurance payments tend to be rather stingy. One of the most common big worker's compensation claims these days, especially in office and retail workplaces, is for employees who are seriously injured or killed in crimes at work. Often, a worker's compensation insurer will give an employer a discount if they have a "gun free" zone, because, statistically, doing so greatly reduces the average amount of harm experienced by employees at work. The presence of employees with guns in the workplace, as an actuarial matter, greatly increases the insurance company's risk of having to pay claims.
It would not be valid in California. see California Labor Code § 2870(a). This will be state-specific and complicated.
No. HIPAA places no limits on who you may share your medical records with - only on those with who your doctors (et al) can share. The HIV laws you refer to, place a positive obligation on you to share the information.
1) Why would an Orthodontia provider want to receive this payment at all in the first place? I was thinking maybe tax reasons. Less cynically, medical providers request that insurance payments be sent directly to them (and you routinely agree to allow them to do so in the fine print of your insurance contract and the paperwork you will out with the provider), every time that they request payment through insurance, because it is extremely uncommon for someone to pay in full and then come up with insurance through which a claim can be submitted. It is set up this way, in part, because medical providers have a lien on insurance payments made to compensate any not previously paid for services that they provided. So, anyway, bureaucratic inertia causes it to happen this way in your quirky case where it really doesn't make sense. Also, insurance companies routinely see claims failed by providers and handle them uncritically, while rarely seeing claims filed by insured for services that have already been rendered and paid for, and so look at those claims more critically, so it was probably in your interest to have the provider make the claim for you on your behalf. More cynically, even if the medical providers doesn't get to keep the money, holding onto it helps their cash flow. It may allow them to borrow less money for operations, or to invest it and earn a return on it. Having money has value even if it is temporary. 2) If they never end up sending me the claim refund, do I have any legal power to fight against this? I have all of the original receipts and an EOP report. Yes. You could write a demand letter, including copies of your evidence, and if they refused to comply within a reasonable time, you could sue, either with a lawyer, or in small claims court. You would have an extremely strong chance of prevailing and in all likelihood they would refund the money before the case went to trial rather than fighting a losing case in court. You have solid evidence that they were paid twice for the same thing. You don't need to bring the insurance company into it (which would make the case much more complicated). You just need to show that your local medical provider got a double recovery and didn't provide a refund. Six to eight weeks is unreasonable when they have already been paid twice. But, given the cost, aggravation and delay associated with suing, you might want to give them some time to provide a refund, although the next monthly billing cycle for them ought to be more than generous accommodation from you.
Not under that name In common law countries, like Canada, the concept is known by the delightfully visceral term price gouging or, in emergency circumstances, profiteering. This is not regulated at a Federal level in Canada. A brief overview of provincial level laws can be found here. Typically, they require prices that are not just excessive - they need to be unconscionable which is a very high bar.
The health insurance contract should set forth what is and is not covered in detail (in addition, there would be a short summary version). They probably don't have to provide procedure codes that are covered or not covered because no such one to one correspondence exists because the language of the insurance contract is controlling and does not exactly correspond to procedure codes. For example, one of the basic eligibility questions is whether a procedure is medically necessary. A procedure may be medically necessary for one person, but not for another, and usually a denial based upon medical necessity is subject to appeal to other medical professionals engaged by the insurance company. Unless the insurance contract provides that an EOB must contain procedure codes, it probably doesn't have an affirmative obligation to do so, because there is no general principle of law that would require them to disclose their internal classification of services provided outside of a litigation context. And, in a litigation context, you probably could obtain procedure codes in discovery from the insurance company, as the code assigned to a procedure on an EOB would almost surely not be privileged or a legally protected secret. It may very well be that the company has an in house set of procedures for certain common diagnosis codes that are routinely allowed or are flagged for review by an insurance company bureaucrat. But, that would ordinarily be considered something of a trade secret of the company and is not a statement of what is or is not allowed under the actual health insurance contract. However, the privilege against disclosing the information in that context would flow from trade secret law and not from the fact that they are PHI. I don't agree that PHI is the correct reason for failing to disclose that information (unless some case law of which I am not aware has interpreted it differently). The federal law definition of PHI is at 45 CFR 160.103: Protected health information means individually identifiable health information: (1) Except as provided in paragraph (2) of this definition, that is: (i) Transmitted by electronic media; (ii) Maintained in electronic media; or (iii) Transmitted or maintained in any other form or medium. (2) Protected health information excludes individually identifiable health information: (i) In education records covered by the Family Educational Rights and Privacy Act, as amended, 20 U.S.C. 1232g; (ii) In records described at 20 U.S.C. 1232g(a)(4)(B)(iv); (iii) In employment records held by a covered entity in its role as employer; and (iv) Regarding a person who has been deceased for more than 50 years. The cross reference to 20 U.S.c. 1232g(a)(4)(B)(iv) reads as follows: (iv) records on a student who is eighteen years of age or older, or is attending an institution of postsecondary education, which are made or maintained by a physician, psychiatrist, psychologist, or other recognized professional or paraprofessional acting in his professional or paraprofessional capacity, or assisting in that capacity, and which are made, maintained, or used only in connection with the provision of treatment to the student, and are not available to anyone other than persons providing such treatment, except that such records can be personally reviewed by a physician or other appropriate professional of the student’s choice. In short, it is B.S. that you are being given an illegitimate reason for not complying with your request, but it is probably still within the company's rights for other legitimate reasons to deny your request.