treatment denied after the fact
March 25, 2010 12:30 PM   Subscribe

Physical therapy was deemed medically unnecessary after the fact; is the medical provider responsible at all?

I've seen this thread, but my question is more about me vs. medical provider than me vs. insurance.

I have Anthem in California. I'm allotted 24 physical therapy and/or chiropractic visits per year. Last year I got chiropractic, finished that, then had physical therapy prescribed by my primary doctor.

I lost count of my visits, and went over the limit. After four appointments over the limit, Anthem sent the PT a letter saying that I was out of visits, and that the PT needed to call for preauthorization. The PT didn't call, and didn't tell me anything; I had four more appointments after that letter was sent, before an EOB clued me in.

Cue five months of Anthem requesting treatment notes and the PT not sending them. They finally did, everything was denied after MD review, and now I have a $1500 bill. I'm appealing, but not optimistic.

I suspect this will come down to the fact that I am responsible for keeping track of my own visits. That being said, is it reasonable for me to try to negotiate with the PT, given their failure to respond to Anthem or notify me?
posted by moonlet to Health & Fitness (8 answers total)
is it reasonable for me to try to negotiate with the PT

Anything, including health care, is negotiable.

Also, check and see if the PT is charging you the same rate that they charged your insurer. They may have a different negotiated rate with the insurance co than they do for patients off the street.
posted by zippy at 12:42 PM on March 25, 2010 [2 favorites]

Not as a legal matter, but as an ethical and common sense matter I would personally attach a lot of significance to the fact that the PT was on formal, written notice that you were out of visits. The PT was on notice that action on his/her behalf was necessary to secure your benefits, and PT knowingly declined to either take that action or advise you. Personally, I would deem the failure to act in response to the notice as a waiver by the PT for visits that took place after receipt of the letter. I want to be clear however, that I say that as a personal matter without any knowledge of California law. My answer is not legal, it is personal preference. I think you could make a strong emotional, ethical and business argument accordingly, but I cannot and am not giving any advice on your legal rights and responsibilities.
posted by bunnycup at 12:47 PM on March 25, 2010

I would think the PT would be liable for any visits after they were notified of noncoverage by Anthem, unless they can prove they told you that you are responsible for them. Send them a certified letter.
posted by neuron at 12:49 PM on March 25, 2010

This is going to sound a little counter-intuitive, but call Anthem first. Ask them if the PT is contracted with them, and if so, if the PT is contractually obligated to get pre-auth before visits. If the PT is contractually obligated to do those things, tell Anthem that they are billing you because they didn't. Anthem will intercede on your behalf and most likely, you won't owe anything. If not, you're SOL because if you see some one who isn't contracted (usually listed as "in-network") it's your responsibility to deal with the insurance stuff.
posted by dogmom at 12:49 PM on March 25, 2010

They should have done a better job. Go sit down with the manager and see if you can get a massive break on the cost.
posted by theora55 at 4:17 PM on March 25, 2010

The PT seems like a real screw up. Yes you are liable for the money, as you knew you only had 24 visits. However this should be appealed like crazy. Make sure you have copies of your treatment notes and write in to Anthem telling them of your progress and how the extra visits were needed... etc. Ask them specifically why they are denying this and ask for the details. They will pony up the money if they don't have a good reason.

Also if this does get completely denied by your insurance company and you have to pay out of pocket, you should negotiate a lower rate that what the insurance company was charged. I've worked for doctor's offices they do this as a courtesy to the patient. I also do medical appeals for a living. Memail if you want/need anymore info.
posted by Attackpanda at 4:26 PM on March 25, 2010

Everywhere I have ever worked keeps track of how many visits the insurance gives the patient, and when we need to reapply for authorization. If I accidentally lost track and the patient got charged out of pocket for visiting me, I'd be mortified and do everything I could to give them a break on the cost. One PT's opinion.
posted by jennyjenny at 2:36 PM on March 26, 2010

I agree with jennyjenny above, that has been my experience also. That being said, most places ask you to sign a document stating that you are resonsable for anything that insurance does not pay. How did you choose this clinic? If your doctor recommended or referred you to it, I would send him/her a letter suggesting not recommending this place to other patients, recounting you experience, and cc it to the clinic. PT's ar dependent upon referrals from physician, and the last thing a PT wants is to get on an MD's bad side. Good luck.
posted by Lost at 7:24 AM on March 27, 2010

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