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Thats an interesting kind of insurance. How much are the premiums?
That's what we have to. It's a high deductible HSA. We have a 3k deductible per person/ 5k max for the family after the deductible is met person or family the insurance pays 100% of everything. My husbands company puts something like 163$ a month on our HSA card for us to offset the deductible. I usually meet the deductible in about 2 months, but thanks to the card it's not bad. We pay 73$ a month for the family to have coverage.
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.
Suzy, you are 100% correct. We are missing a lot of the story here and a lot of assumptions are being made. People are jumping to some pretty serious judgements here both against the doctor's office and the insurance company when this all could simply be a matter of the OP's not understanding his or her insurance coverage.
I encountered that many times when I paid health insurance claims. But if the client was willing to listen, and talk, I was always willing to go through the claim together with him or her. The person who handles the insurance business at the doctor's office is usually willing to do the same. If these methods fail, there are companies that are advocates for the patients who will step in and help them. Some will do it at little cost some for a small percentage of whatever fee is collected. Some state agencies will help but those are usually for large disputed billings.
The point is to just try to stay calm and talk to the people involved about the problem. Trust me, when someone would come at me with threatening letters or attitudes before we even got a chance to open their file, I would not be inclined to be on their side. The reasons for the confusion can be mistakes being made, we are all human, misunderstandings or any number of things. There is no reason to begin the conversations with hostility. Most problems can be resolved. If they can't then the patient can decide to take more drastic action. But the person questioning why things were done needs to understand the reason first and foremost.
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.
He's not disputing the $240. Insurance company is not paying $260. Ins co. processed the claim and approved payment for $240, which OP is to take from his employer-funded debit card. Doc wants, instead, the entire $500 - not the contracted in-network amount of $240.
Per this:
Quote:
Originally Posted by zibrnp
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 $240 is not coming from my pocket only from the allowance that I should use for payments to doctors and prescribed medications.
The doctor is refusing to send other claims to the insurance company and telling me that I need to pay his official fees.
His insurance company processes his claims, as follows:
Quote:
Originally Posted by zibrnp
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 seeing the $240.00 on the EOB that said the OP was responsible for that amount. If the doctor is billing him for %500, is he getting an itemized billing? Did he say he reported this to the insurance company that said he owed only $240.00? I am not understanding this story then. Why is the insurance company being blamed for a charge his doctor is illegally charging if this is the situation?
I admit then I am not understanding the situation. It seems to me that the doctor's office and the insurance company needs to discuss the contract they have between them but I still have a hunch that we are not hearing the entire story correctly from the OP.
He's not disputing the $240. Insurance company is not paying $260. Ins co. processed the claim and approved payment for $240, which OP is to take from his employer-funded debit card. Doc wants, instead, the entire $500 - not the contracted in-network amount of $240.
Per this:
His insurance company processes his claims, as follows:
OP's issue is not with the first claim, it is with the doctor's office not filing the other four visits with the insurance company.
I do not see a post where OP says he was asked to pay the entire amount for the first visit.
OP's issue is not with the first claim, it is with the doctor's office not filing the other four visits with the insurance company.
I know that. I clearly stated above in my response to Minervah - there are four other visits she refuses to submit to the insurance. Minervah believed he wasn't willing to pay her even the $240 - the amount ins. co. said he could pay her from the debit card.
Quote:
Originally Posted by suzy_q2010
I do not see a post where OP says he was asked to pay the entire amount for the first visit.
You are correct. That is an assumption (erroneous?) I made because nowhere did OP say he paid for the first visit. Did the doctor actually take the $240 from the debit card? A leap I made on facts not in evidence.
I know that. I clearly stated above in my response to Minervah - there are four other visits she refuses to submit to the insurance. Minervah believed he wasn't willing to pay her even the $240 - the amount ins. co. said he could pay her from the debit card.
You are correct. That is an assumption (erroneous?) I made because nowhere did OP say he paid for the first visit. Did the doctor actually take the $240 from the debit card? A leap I made on facts not in evidence.
If she is out of network the doc does not have to submit the claim. She is not just "refusing" to do so. If she is out of network, she is entitled to ask for the full fee. Some offices will file out of network claims. If they do, the insurance company sends a check to the patient to reimburse the out of network benefit directly to him. But many offices just provide a receipt for the patient to send to the insurance company himself.
OP has not demonstrated to my satisfaction that the doctor is in network. He needs clarification from the doctor's office.
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