Please register to participate in our discussions with 2 million other members - it's free and quick! Some forums can only be seen by registered members. After you create your account, you'll be able to customize options and access all our 15,000 new posts/day with fewer ads.
The doctor cannot suddenly decide to charge you more, this is a violation of the contract. Further, she cannot try to collect above and beyond what the contracted rate, your portion, is.
Call the provider network department of your insurance.
+1.
From what you have said it appears a breach of contract. Call the insurance company.
The insurance company has no legal enforcement power over that doctor - nor can it prevent her from fraudulently billing OP - nor scare her. If she's in-network, the only recourse for the insurance company is to remove her from their network. Which is what she wants.
Doesn't matter if regulatory agencies in the end can't effect a resolution. The mere threat of reporting - in my case, I actually did report to the BBB - and got INSTANT resolution. Didn't matter that BBB doesn't have any enforcement capabilities - the fact that I aggressively went public got this festering issue immediately settled.
In my case it was so Mickey Mouse - with doctor and health insurance company passing the buck - BUT I was the one against whom the doc would be eventually filing a collection action if I allowed it to go on - so I nipped it in the bud.
Might have been swatting a fly with a sledgehammer, but it worked. In cases like this, I believe in overkill - especially when I am being scammed.
The doctor send a claim to the insurance for the first visit and billed them $500. Insurance company approved the claim and sent explanation of benefits to me and the doctor stating that I have to pay $240 and I am not responsible for the other difference ($260).
I must be missing something. The insurer is stating the patient's responsibility is $240.00. Where did the physician demand more?
I must be missing something. The insurer is stating the patient's responsibility is $240.00. Where did the physician demand more?
Here - for the other four visits:
Quote:
Originally Posted by zibrnp
I have seen her so far 5 times.
The doctor send a claim to the insurance for the first visit and billed them $500. Insurance company approved the claim and sent explanation of benefits to me and the doctor stating that I have to pay $240 and I am not responsible for the other difference ($260).
The doctor is refusing to send other claims to the insurance company and telling me that I need to pay his official fees.
The doctor send a claim to the insurance for the first visit and billed them $500. Insurance company approved the claim and sent explanation of benefits to me and the doctor stating that I have to pay $240 and I am not responsible for the other difference ($260).
I must be missing something. The insurer is stating the patient's responsibility is $240.00. Where did the physician demand more?
OP had four more visits. It seems odd that it took that number of visits before he found out the insurance was not being filed. If he was not paying anything at the time of the visit, he should have gotten a statement at some point. Unless all five visits were in one billing cycle, the problem would have surfaced sooner. Did he ignore any statements he received?
Until the OP resolves the issue of whether the doctor is in network, letters denying any responsibility for the bills and insistence that the claims be filed with the insurance company are premature. If the doctor has resigned from the network, visits after the date she resigned are out of network. Insurance company physician lists are often so out of date that they include doctors who have retired, died, or moved out of the geographic area served by the plan.
If the doctor is out of network, that usually will be brought up at the time of the visit. If the doctor resigned from the network but did not notify the patient, then it should be possible to negotiate the fee down to the in network rate. The best way to do that is to go to the office and ask to speak to the person who handles the insurance claim. If that person cannot resolve the issue to the satisfaction of the OP, he could suggest having the insurance person in the office call the insurance company while he is there and iron it out.
Right now all we know is that OP has some kind of health savings account. We do not even know what the actual insurance company is that claims are to be filed with.
Until the OP resolves the issue of whether the doctor is in network, letters denying any responsibility for the bills and insistence that the claims be filed with the insurance company are premature. If the doctor has resigned from the network, visits after the date she resigned are out of network.Insurance company physician lists are often so out of date that they include doctors who have retired, died, or moved out of the geographic area served by the plan.
If the doctor is out of network, that usually will be brought up at the time of the visit. If the doctor resigned from the network but did not notify the patient, then it should be possible to negotiate the fee down to the in network rate. The best way to do that is to go to the office and ask to speak to the person who handles the insurance claim. If that person cannot resolve the issue to the satisfaction of the OP, he could suggest having the insurance person in the office call the insurance company while he is there and iron it out.
My position would be once the doctor entered the Network that if he resigns, the burden should fall on him to make it clear to the patient that he no longer belongs and that full payment is expected.
The patient has a right to reasonably rely on information he gets from his insurance company. If the doctor leaves the network during treatment that involves multiple visits, I would again assert that the burden falls on the physician and his/her staff to disclose this to the patient.
Why? The physician generally maintains a staff that does nothing, but deal with insurance companies. As such, they are better suited to know things like this than the patient. Otherwise, one is basically expecting a patient to inquire each separate time he seeks treatment. He shouldn't be required to do so.
Report the doctor to your insurance company - it's illegal for her to represent herself as participating but then not to. This happened to me w/a former dentist who tried to force me to pay beyond what insurance was paying although he was participating. After I reported him to my insurance company, I never heard more about it and they dropped him from their list of participating providers.
She is definitely in the network, I checked the website and called insurance company. They confirmed that she is in the network.
The reason she does not want to send it to insurance is that they are not going to approve the amount she is going to say. They will approve what the contract says. She dos not like it and wants me to pay her crazy amounts.
The insurance gives me 6000 a year to pay for visits and prescribed meds.
It works this way:
I go to a doctor
Doctor sends claim to insurance
Insurance approves amount based on contract with doctor
Insurance sends EOB to me and doctor. EOB says "patient responsibility" e.g. $240
I use debit card from insurance to pay doctor who is allowed to take only what EOB says. E.g. 240
I have this insurance for last 4 years and never had any issue.
I was an insurance claims adjuster for over twenty years. From what you are saying this EOB states you are responsible for the $240.00 which is the amount left over after the insurance company has paid their share of the cost for this visit. Patient Responsibility means just that. It is your bill and you have to pay it. If the insurance company sent a copy to your doctor, it would have been for information only to let him know they informed you of your portion of the bill.
Now, clearly there is a huge misunderstanding somewhere along the line. Before anyone starts getting threatening towards anyone else, I suggest you call your insurance company to see if they can't straighten the matter out with your doctor's office if the doctor's personnel won't do it. I used to do this for my clients. But first go to your doctor's office and make certain you understand what's going on there since you seem to believe they are causing the problem.
There seems to be a piece of the puzzle missing here and someone is not understanding how the coverage works. I doubt that the doctor's office misunderstands the difference between in network and out of network since they must deal with hundreds of claims each day. If they have an insurance department or if one person in the office handles insurance claims specifically, go and talk to that person face to face. You will get much better results than writing a letter or trying to deal with the situation over the phone.
My position would be once the doctor entered the Network that if he resigns, the burden should fall on him to make it clear to the patient that he no longer belongs and that full payment is expected.
The patient has a right to reasonably rely on information he gets from his insurance company. If the doctor leaves the network during treatment that involves multiple visits, I would again assert that the burden falls on the physician and his/her staff to disclose this to the patient.
Why? The physician generally maintains a staff that does nothing, but deal with insurance companies. As such, they are better suited to know things like this than the patient. Otherwise, one is basically expecting a patient to inquire each separate time he seeks treatment. He shouldn't be required to do so.
We are missing a lot of information here. Most medical offices do ask about insurance each visit. Patients change plans often. They leave jobs or the employer changes plans. I show my insurance cards to each doctor I see each time I visit. Some people do choose to see out of network physicians. Did the OP ignore one or more statements from the doctor's office that showed a balance due? If he did, he missed the opportunity to find out there was a problem.
It is the patient's responsibility to understand his insurance. He should be able to expect what his insurance company tells him to be accurate, but the fact is that it often is not when it comes to who is on the physician panel. The people who deal with the contracts with the docs are not the same people who are answering questions from patients. When a physician resigns from an insurance panel, that information may or may not be conveyed to the person responsible for maintaining the list.
One insurance company provider website says it updates its doctor list six days a week but "Please check with the provider before scheduling your appointment or receiving services to confirm he or she is participating in [our] network."
It is not fair to the physician to assume the doc is lying if she claims to be out of network, because she probably is out of network. Was the mistake made in telling OP she was in network when she never was with his particular plan? Or did she resign after the first visit? We do not know. All the OP has to do is go to the office and and explain that he thought he was seeing a doctor who was in his insurance network. There will be someone in the office who can figure out what is going on. I suspect that the doctor is indeed out of network. I think you will find that most offices would adjust the fee if they found that the patient was expecting the in network rate and would have chosen a different doctor in order to get that rate.
Please register to post and access all features of our very popular forum. It is free and quick. Over $68,000 in prizes has already been given out to active posters on our forum. Additional giveaways are planned.
Detailed information about all U.S. cities, counties, and zip codes on our site: City-data.com.
Please register to participate in our discussions with 2 million other members - it's free and quick! Some forums can only be seen by registered members. After you create your account, you'll be able to customize options and access all our 15,000 new posts/day with fewer ads.
