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Family Physician
Family Physician, Doctor (MD)
Category: Health
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Experience:  Emergency Medicine and Family Practice for over 26 years
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I have Humana PPO as primary insurance, Regular Medicare is

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I have Humana PPO as primary insurance, Regular Medicare is secondary ( Not an HMO), and Florida Medicaid. I am a disabled dependent on my Fathers Humana PPO. Medicare and Medicaid are under my name only. I go out of state to New York for specialist and surgery. These doctors are out of network for Humana. They are all full participating Doctors in Medicare. They bill Humana. Humana pays max. allowable fee. I get balance billed for difference between max. allowable fee and doctor full bill plus deductables. Doctor bills Medicare and receives whatever they pay and still balance bill me the difference. My question is since they are full participating doctors in medicare shouldn't they have to abide by Medicare rules , and not be allowed to balance bill the total difference. I would really appreciate an answer to this question. If more information is needed just ask.
Submitted: 6 years ago.
Category: Health
Expert:  Walt-mod replied 6 years ago.
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Expert:  Family Physician replied 6 years ago.
I'm sorry for the delay in answering your question:

Generally, a physician who does not participate in YOUR state Medicaid program would be able to balance bill you for difference between the Medicare allowable amount and the Medicare payment (your deductible and 20% copayment).

If however, you meet certain income requirements (see QMB on this link), the provider would be prohibited from balance billing. - 2010-09-07

Your best options are to find a physician who is participating in Humana or one who is participating in your state Medicaid program. I would also suggest speaking with your state Medicaid program to get the specifics on your classification (QMB or not).
Family Physician, Doctor (MD)
Category: Health
Satisfied Customers: 12816
Experience: Emergency Medicine and Family Practice for over 26 years
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