Current PPO. Go to Dr. Rich for colonoscopy. On my explanation of benefits Dr. Rich charged 1k for colonoscopy, 1k for analysis, 1k for biopsy. My insurance says colonoscopy is contracted at $800, and the analysis and biopsy have footnotes. These footnotes state that these procedures are considered part of a colonoscopy. My responsibility is my $50 specialist copay. I have never had a doctor attempt to bill me directly for a procedure that insurance company denies payment to.
HDHP. Same scenario above. How is this three way contract between myself, my insurance, my doctor and my doctor's contract handled? Would the doctor's contract with the insurance company ensure that insurance decision on procedures are "binding"? Or, could the doctor send me a bill for the two procedures that the insurance company states is not payable? If I pay a procedure that my insurance company does not consider 'reasonable/customary' does this apply to my deductible?