Can a provider balance bill me more than 180 days after insurance pays the claim?

One of our medical providers was paid promptly on their claim by our medical insurance company, but they waited six months to balance bill me, and they refuse to honor the provider discount that was deducted by the insurance company. I paid the provider the amount indicated as my financial responsibility on the EOB form, but the provider wants me to also pay them the provider discount. It's past the 180 days that I can file an appeal with my insurance company. It doesn't seem fair or even legal for the provider to do this when I have no opportunity to correct the mistake the insurance company might have made - if they did make a mistake at all.
Additional Details
I am in the state of Washington, but the insurance company is Humana Health Insurance Company of Florida. My husband's employer is headquartered in Florida.

The provider is not in the network, but the EOB indicates that services were discounted according to "Mulit-plan Inc. agreement."

The important thing for you to find out is whether or not the provider really is obligated to honor the Multiplan discount.

I'll explain to you how it works, as I deal with these types of networks on a daily basis...

Networks like Multiplan contract with providers to be a "back-up network" for people who are out of their home plan's state. (For example, in this case your insurance company is Humana of Florida. You live in Washington state, so apparently Multiplan is your secondary network for services in your state.)

There's a couple pieces of information that you'll need to find out...

1) Does the Multiplan logo appear on your insurance card (usually on the back)? If there is no Multiplan logo, stop right here. A provider is never obligated to honor a Multiplan discount for you if their logo isn't somewhere on your insurance card. (All of Multiplan's provider contracts have a clause against "Silent PPOs" - the provider needs to be aware that you will receive the Multiplan discount at the time of your services.)

2) Was the provider legitimately contracted with Multiplan on the date of your services? (Sometimes there are mistakes on EOBs when it comes to these secondary/out of state networks.) You can find out whether the provider was contracted with Multiplan on that date by calling Multiplan directly: 800-672-2140. Specifically ask about your date of service when trying to find out whether the provider is contracted with Multiplan. (Also...Multiplan's provider directory is available online here: http://www.multiplan.com/ )

If you find out that your provider was definitely contracted with Multiplan on your date of service *and* you do have the Multiplan logo listed on your insurance card, then this is what should happen: Either Multiplan and/or Humana of Florida should send a letter to your medical provider on your behalf reminding them of the contract and that they shouldn't balance bill you. You should also be CC'd on this letter for your records.

If the Multiplan logo is not on your insurance card and/or you find out that the provider did not have a Multiplan contract on the date of your services, then this is what should happen: A new EOB should be generated for you, showing that the balance bill amount is actually your responsibility. (Sorry.)

Multiplan, your insurance company, and the medical provider should still be able to get this resolved. All of Multiplan's contracts allow the provider 12 months from the date of service to get pricing/discount issues resolved. So, even though you aren't within the appeal timeframe with your plan, the medical provider should still be within the time frame they are allowed according to the Multiplan contract.

You need to post what state your in and what company your dealing with.

If you have a problem file a complaint with your state's Insurance Commissioner or Dept. of Insurance.

You have an EOB that states the the provider was paid a contracted rate and what you owe. Contact the insurance company and tell them that their contracted provider is billing you the balance and they should be able to call the provider and get it straightened out. By billing you for the balance, the contracted provider is violating the agreement they have with the carrier.

EDIT:After reading your further post, I will offer this. Call the insurance company again and ask for a supervisor. This needs to be dealt with and you need to be the squeeky wheel. Reiterate to them that this was paid as in network and the provider is balance billing you which is a violation of their agreement. If the provider is no longer an in-network provider, they (the insurance) MUST reprocess the bill. If you do not get any satisfaction, send a certified letter to them , the provider and cc the state insurance commissioner's office in Florida for resolution of the matter.

You are going to LOVE my answer...you are out of luck.

If the provider is not in the network (and I would be willing to guess its an anestheolgist, pathologist or radiologist) the insurance has no authority to deal with them. There is no appeal. Humana DID process the claim correctly. They paid (adjudicated) the claim according to the rules of the contract. Which means they paid the provider the amount they would have to pay an in-network provider, but because insurance companies know that some providers aren't in any network, they don't penalize you using the out of network benefit.

If it makes you feel any better (though I doubt it), this isn't a Humana issue. Its an industry wide issue and its why we have so many docs coming out of med school and going to these specialties...they don't have to deal with insurance companies!

~~II would definitely appeal this. I would send a photocopy of your EOB to the provider billing you and tell them you will file with the State Insurance Commissioner if they harass you any further. Then I would call your insurance company and ask to speak with the legal department. Tell them you are being balanced billed, and you want action from them on your behalf or you will file with your State's Insurance Commissioner. The only thing this provider can do is turn you into a collection agency. If the balance is under fifty dollars, they won't they will just write it off. If it's over this amount and they do, then keep copies of all correspondence as well as date, time and person you spoke with log, and send this information in to them. It will become a legal matter and they can't really do much until the provider and your insurance show proof you should be collected on.
To answer the part of the 180 day billing, yes they can bill as late as 12 months later.~~

You don't have to appeal the claim with your insurance. Just notify them that the provider is balance billing you over their Multi-plan contracted rate. The insurance company will have a process for handling it (either paying the balance or letting the provider know they need to stop billing you).

Is the provider "in network"? If so, then they have to accept the insurance discount. If they are not in-network, they do not.

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