Final answer:
A participating (PAR) provider typically cannot bill a patient for the difference between their charged fee and the insurance company's allowed amount; this is often against their contractual agreement with the insurance company. However, the patient is responsible for any copayments, deductibles, or coinsurance as defined by their insurance plan.
Step-by-step explanation:
Can a PAR provider bill the patient for the difference between their fee and the insurance company's allowed amount? The answer to this question generally depends on the agreement between the provider and the insurance company. In a fee-for-service health financing system, medical care providers are reimbursed according to the cost of services they provide. However, within health maintenance organizations (HMOs), medical care providers receive a reimbursement based on the number of patients they manage, not necessarily the individual services provided.
Concerning the billing question, if a provider is a participating (PAR) provider with an insurance plan, they usually agree to accept the insurance company's allowed amount as full payment, minus any copayments, deductibles, or coinsurance required by the patient's benefit plan. It is generally against the contract for PAR providers to bill patients for any difference, a practice known as 'balance billing.
However, adverse selection can impact health insurance markets when insurance buyers have more knowledge about their risks than the insurance company, leading to imbalances that may not directly relate to billing between the provider and patient but affect overall insurance costs and premium settings.
Insurance plans such as Part B can introduce patient costs through monthly fees, deductibles, and copayments, where the government subsidizes a portion of the costs, showing a shared responsibility model. Insurance lowers the individual's price for health care, but not the cost to insurance companies or society, as additional insured services can lead to increased usage and higher overall costs. Increases in insurance costs are then often transferred back to the patients through higher premiums or taxes.