Treatments deemed unnecessary after the fact, do we have to pay?
June 15, 2008 4:12 PM   Subscribe

Several months after her last visit to physical therapy, my fiancee was informed that her health insurance company won't pay for the last two months of it because they didn't think it was "medically necessary". Even if she upheld all her obligations, including co-pays every visit, is she liable for these charges? (more details inside)

Some details:
- Jan: She was referred to an in-network physical therapist from her primary care physician due to pain from a back injury.
- June: Almost 5 months later the therapist stopped therapy as they felt they had done all they could do. She had paid her co-pay every visit and had even inquired about whether she needed additional referrals from her physician, to which she was answered no.
- Nov: Almost 6 months after the last visit, she was informed by the health insurance company that they weren't paying for the final two months of visits due to lack of "medical necessity".
- Feb: The physical therapist starts sending us bills for the final two months of treatment.

Since then we have appealed the "medical necessity" assessment with the health insurance company and were denied. They essentially said they had repeatedly asked for additional notes from the therapist regarding the final two months, and once they received them had deemed the treatment ineffective (and unnecessary) because she wasn't demonstrating the required improvement to prove the ongoing treatment medically beneficial.
We have also filed a complaint with the Illinois Dept. of Insurance, but they essentially said there is nothing they can do.

The therapist is getting aggressive and threatening to call a collections agency if we don't pay several thousand dollars.

We feel that at some point during those two months someone should have at least let us know these treatments might not have been covered instead of half a year later. We are mostly upset with the therapist because it seemed like they racked up 60 days worth of charges even while the insurance company was not paying them, all while my fiancee was never informed or given alternative options. We have researched things quite a bit, but short of getting a lawyer, haven't found any details in terms of legal obligations and obligated time frames that might help us out. Any help or suggestions from the hivemind?
posted by Sloben to Health & Fitness (10 answers total)
Honestly the only good answer you are going to get is a reference to an attorney. Only they can adequately layout your options. But you're probably going to sue in order to get any recourse here regardless of whether you are wrong or right (IANAL but it sounds like you have a legit grievance and if you sue the physical therapist it may not be worth the legal bills for them to follow up).
posted by bitdamaged at 4:47 PM on June 15, 2008

How many times have you gone back to the insurance company? I know I've had to write and rewrite letters several times in the past to get mine to cover stuff that is *specifically and clearly* supposed to be covered in the contract, and *still* had it denied over and over. It basically turns into a test of wills.

If you have the time and the inclination, I'd advise sending a letter to the therapy office - or meeting with them in person - letting them know that you're duking it out with the insurance (they'll be used to how long those things take). Then put on your boxing gloves and get pig-headed, and start writing notarized letters to the insurance company. Document, document, document.

If you have a lawyer that can draft a letter to the insurance company, it would probably make the process shorter and easier for you. Also there may be something in your insurance company that says how long they have to notify you that they're not going to cover charges, which would give you an easy out, and which the lawyer would be able to spot in the fine print.

But it does sound like you have a leg to stand on, so to speak, so don't give up just yet.

Best of luck!
posted by GardenGal at 6:34 PM on June 15, 2008

The short answer is that she is responsible for all of the PT's charges and that any issue of payment by the insurance company is between her and the insurance company. The PT did what he was requested to do and wants to be paid. Those are the legal obligations.

A longer answer has to come from a lawyer who represents you.

Note that the insurance company did not inform her of its position for five months. It is likely that it did not respond any faster to the PT. Hence this may not be accurate:

>it seemed like they racked up 60 days worth of charges even while the insurance company was not paying them
posted by yclipse at 6:40 PM on June 15, 2008

By the way, I think your "leg to stand on" is more based on the fact that the insurance people are not doctors and cannot make the final determination of what's medically necessary or not... rather than the timeframe (however irritating and irresponsible).

Can you get a letter from the therapist in question stating as his/her professional opinion that the procedures *were* in fact medically necessary? If you can get a letter from an actual doctor - hell, especially if you also got a corroborating second opinion from another therapist - that might go a long way to proving the insurance company in the wrong.

Whatever you do, find a way to not pay yet. Once you've paid, the insurance company has no incentive to work with you.

By the way, I know it doesn't help but I feel really angry for you. Would they refuse to pay for an antibiotic if you were in the hospital suffering from suppurating wounds, and antibiotic A didn't work and they had to switch to Antibiotic B? I don't think so!
posted by GardenGal at 6:41 PM on June 15, 2008

Whatever you do, find a way to not pay yet. Once you've paid, the insurance company has no incentive to work with you.

I don't think that's true. See yclipse's response, which is also my understanding. The patient is ultimately responsible for all charges, so you do need to find a way to either start paying on the bills or to get a lawyer involved who will have to work something out with the office. Do not let it go any further without paying something. We've had some monster medical bills over the years and every office we've worked with has been willing to take $50 or $100 a month. If you get the insurance company to pay out, you'll get your money back.

What I'm surprised about is that the state office says there's nothing to be done. Is it a self-insured plan?
posted by cabingirl at 7:36 PM on June 15, 2008

Response by poster: Thanks for all the comments and suggestions.
In case any body's still following this: We've sent multiple letters and gone through the appeal process with the insurance co. They basically are standing by their decision as based on the notes they received from the therapist that showed to them she wasn't making sufficient progress (as expressed in actual quantified metrics like % gain in flexibility, etc.) to warrant the ongoing therapy. I know we can pursue another appeal including a independent medical reviewer, but I have a hard time seeing how they could interpret the therapists own notes differently. The response from the state complaint followed similar lines, and they showed where the insurance company had supplied letters documenting their various requests to the therapist during this time period (on all of which we were never copied). We plan on discussing this further in person with the therapy co.
My fiancee was a student at the time and had insurance through the university. My very limited understanding of this is that this does fall under the "self-insured" category, which we realize might complicate things in terms of responsibilities.
I guess our main frustration is that we were never notified during that two month period that these treatments might not be covered by insurance (even though we were paying co-pays) and that we should pursue other (cheaper) options. We were mainly looking for some leverage in the form of mandated time frames that might prevent two months worth of expensive medical charges from unknowingly adding up (i.e. something along the lines of "you can only accrue xxx weeks of treatment before being notified it was not being covered").
I know this is a lot of details, but thought I'd see if anybody had any similar experiences.
Thanks for reading!
posted by Sloben at 8:38 PM on June 15, 2008

I can tell you from personal experience that what you need is a letter from the referring MD stating that the additional treatment was necessary.

In future, don't go over the number of prescribed treatments without getting another prescription.
posted by fshgrl at 10:35 PM on June 15, 2008

Q> Was the therapy prescribed by her physician? If so how many sessions?
Q> Who usually determines if the therapy is no longer required? If the therapist is the answer then the therapist is, or should be, held responsible for providing services that he/she knew or should have known were ineffective, no longer prescribed, and or no longer covered.
posted by Gungho at 4:42 AM on June 16, 2008

Depending on the jurisdiction in which you live, "assignment of benefits" (AOB) is a payment method of which you should be aware, that may even still be beneficial to your position in this case. Given that you state your fiancee patronized an "in network" PT, if she also assigned her health plan payment benefits at the time she began treatment, she may have created a binding obligation on the provider to accept the "customary and reasonable" payments offered by the health insurance company, in consideration of assigning her payment benefits. Many health care plans require this of network affiliated providers, as a means of controlling their costs, and many health care providers do AOB as a means of securing quicker cash flow, and of documenting their treatment performance to the health insurance company. If your fiancee assigned her benefits, and you make a big enough stink about this with your health insurance provider, and copy that correspondence to the PT, suggesting that the PT's failure to accept their payments, or benefits assignments as payment in full may be part of a billing system intended to generate extra payments from plan subscribers, that you want to check before paying additional claims, you may build considerable leverage.

Generally, providers want the expedited cash flow that being in a network, and accepting payment assignment provides, and are unwilling to jeopardize this, by being eliminated from from health care networks and their referrals, for such reasons as you've laid out here. Such complaints as you might make sometimes trigger larger reviews, that reveal ongoing patterns of billing which amount to ethically questionable behavior, that gets health care providers tied up in major payment battles with health care companies, or even dragged into court.

You've been treated unprofessionally, and even shabbily. Don't roll over, and do push back. Explore the "assignment of benefits" issue, write letters documenting your position, and seek the advice of an attorney, if needs be.
posted by paulsc at 4:54 AM on June 16, 2008 [1 favorite]

In the meantime, you ought to arrange a payment plan with the therapist so that the collection agency won't be called.
posted by herbaliser at 1:22 PM on June 17, 2008

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