Health insurance question

May 21, 2009 12:13 PM

Health insurance question: my insurance benefit ran out for a recurring doctor's visit. The doctor knew this - I didn't - and they kept accepting my copay as if nothing had changed. How do I proceed?

My maximum benefit for physical therapy was reached in early July of 2008. I was not aware of this, but clearly should have been. The medical center was aware of this, as confirmed by my insurance company at the time (I just found out someone from the doctor's office called to check on my benefits in late June 2008).

I continued to go and pay my copay until August of that year. Early this year I started getting bills for the uncovered amount (2 grand). How should I proceed?

Again, I know I am responsible, but it seems unfair that they didn't let me know and continued taking my $10 every week as if insurance was still covering. Should I just ask for some kind of payment plan or do I have grounds to question the whole thing? Does anyone have experience with this? Many thanks for any help.

posted by JamesWilson123 to health & fitness (10 comments total)

Payment plan.

Sorry, but questioning the whole thing will just cost you more, and you'll end up being defeated anyway. There's basically guaranteed to be a clause somewhere in the fine print saying you agree to be on the hook when the insurance stops.

My phys therapist did the exact same thing, except that I noticed almost immediately (relatively proactive insurer), so I had time to bail out with only a few hundred bucks due. I suspect physical therapists do this on purpose because they know that patients bail out immediately once the insurance coverage is gone.

...I suspect that it's intentional because my friend had a phys therapist who did exactly the same thing to her as well, which once we add you makes it 3-for-3 in my experience.
posted by aramaic at 12:38 PM on May 21

You don't say what kind of health plan you have, but if it's an HMO or PPO it might be worth your while to submit an appeal to your plan to have them reconsider these charges.

Explain the circumstances, and if there is proof that the provider was at fault and they are contracted with the HMO or PPO, and the health plan decides in your favor, then the health plan can MAKE the provider eat those charges!

If your appeal is denied, all it cost you is the time that it took to put the appeal together. Good luck!
posted by Hanuman1960 at 12:50 PM on May 21

Aramaic is right, you're gonna have to pay. BUT: Make sure you're not being billed more than the insurance company would cover.

If you get a statement of benefits from your insurance company it often has a line-item breakdown indicating that the visit amount was, what the allowable amount was, and an adjustment by the doctor's office for the difference.

For example, your doctor might bill $80 for a pedurahtz. (which I just made up)
Your insurance company says they only pay $65 for a pedurahtz. They pay your doc that amount.
Your doc credits you $15 for the difference.

It's not unusual for the office to initially attempt to bill you the $80 amount, however, since that $65 price is predicated on the agreement they made with the insurance company. You don' t have any such arranged agreement.

You should insist on getting the same deal, particularly since they kept treating you as if you were (by charging you the copay). Don't be afraid to negotiate. You are in the position of having the money they want. It's in their interest to negotiate with you rather than engage the services of a bill collector, particularly since you can really make a bill collector's job hard if you put your mind to it.

I don't suggest you do, but I see no reason not to use it as a bargaining chip. They didn't deal with you on very good faith (or at least were sloppy in not telling you what they knew) so why shouldn't you play a little hardball with them?
posted by phearlez at 12:53 PM on May 21

Realize that while 1 person in the billing department of your Phys Therapist might have known, it's unlikely that they would have let any sort of special note in your file for the receptionist.
posted by nomisxid at 1:34 PM on May 21

I just wanted to second what phearlez said, but also: particularly with this provider, this approach might work once. Going forward, always stay on top of your insurance, especially if you have recurring appointments. The good-faith thing to do on the provider's part would have been to call you up and tell you, but in reality, they don't always do this. In the end it's the patient's responsibility to be on top of his or her benefits.

But certainly give them a call, explain the situation, and request that they charge you the contracted amount that they would have charged the insurance.
posted by DrGirlfriend at 1:55 PM on May 21

I've been through several rounds of PT and same thing happened to me each time. I kept showing up for my appointments, no one said anything, and months later I get a bill for the entire whopping amount.

I've learned to just stay on top of it by calling my PT's accounting office and finding out the limit of my coverage in advance.

You probably did sign something when you started treatment agreeing that the you are responsible for what your insurance doesn't cover. It would have been nice for the PT office to notify you in advance, but at the end of the day, it is your responsibility.
posted by choochoo at 2:07 PM on May 21

I had the same experience during Uni. We had this mandatory health plan that covered sod all, so I usually ended up paying hundreds per year out of pocket. My primary GP recommended physical therapy for some aches I was having. So I went and figured I'd be okay, since I knew he was covered under my plan. What I hadn't been told was that they only covered $25 per visit. He billed about $120 per visit. So I ended up stuck with a bill of $600. After that, I said never again.

The way it usually works it that when you sign the bottom of your medical history questionnaire, there's a clause in there that says you will pick up wherever your insurance leaves off expense-wise. I have yet to find a doctor or practitioner who doesn't have that. I would suggest calling them up and seeing you can arrange a payment plan.
posted by arishaun at 5:21 PM on May 21

It's doubtful the provider was at fault Hanuman1960, they just didn't say when the benefits ran out. Which I agree is a lame ass thing to do. But they expect the receptionist to know insurance, and the insurance back office peeps like myself stay the hell away from patients.

I'd say go for a payment plan and only pay what your insurance pays. The doc's office I worked was happy to do it that way.
posted by Attackpanda at 7:15 PM on May 21

err... don't expect the receptionist. Stupid fingers!
posted by Attackpanda at 7:16 PM on May 21

This is a negotiation. I would start out with a much harder line than what the insurance pays. I would research what the collection agency will buy this for and top that slightly. Delay. Continue to negotiate. It may even be worth having it go to collections and negotiating with them. A lot depends on your tolerance for notes to your credit score too over cash in hand. Some would pay not to have a lack mark and others would rather keep the cash.

Also, I would talk to insurance company and find out under what circumstances they would have paid it. Maybe you can get a doctors letter saying you needed the additional therapy. I assume if you kept on going it was because you were not fully recovered. I have had therapy extended with the help of a doctor.
posted by JohnnyGunn at 10:19 PM on May 21