As further evidence that the capped amount was intended to be the sole payment , there are a few specified exceptions that set forth when a provider may turn elsewhere for payment :
• When benefit limits of a policy have been exhausted , a provider may bill the insured for the remaining services not paid under the automobile insurance policy . In this situation , the provider may bill secondary insurance if it exists , and payment shall by made under the terms of that policy , without regard to the medical cost containment provisions of Act 6 .
• If no portion of the provider ’ s bill is payable under auto insurance coverage , payment limits are no longer applicable to payment and the provider may either bill the patient directly , or bill the secondary insurer .
The fact that Pennsylvania Code sets forth instances in which a provider may turn to other sources of payment indicates that a provider should not turn to other sources in other situations not authorized by the Act .
Example I : Assume an insurer ’ s auto insurance limits have not been exhausted ($ 5,000 medical benefits ) and the auto insurer receives a provider ’ s bill of $ 13,000 that is reduced to $ 7,000 when factoring Medicare reimbursement rate . The bill still exceeds the auto policy limits by $ 2,000 . Since there is no applicable secondary insurance , the provider may bill the patient for the difference between the Medicare reimbursement rate ($ 7,000 ) and the policy limits ($ 5,000 ). Therefore , the patient can be billed $ 2,000 in this case .
Example II : In the case above , if coverage were available from a secondary insurer , the provider may bill the secondary insurer for the full remaining balance of $ 8,000 ($ 13,000 charge less $ 5,000 policy limit ). The secondary insurer will determine the appropriate amount of payment to the provider under the terms of the patient ’ s policy .
2022