Question
What is the name of your state? NJ
I actually have two issues, but I think only one is relevant in this forum, so I'll stick mostly to that.
I called a Therapist's office to see if I was covered for mental health visits and what the cost would. The office took the information from my card, called the provider, they were told that I was covered (apparently), and came back and told me it was a $30 co-pay up to 20 visits a year. So I setup appointments with them (8 over a 4 month period) and never heard anything to the contrary until 4 and a half months later, when the therapist's office called and said the Insurance company decided that I actually wasn't covered, and they were going to take back all of the payment that they had made to the office, and that I was now responsible for the full price of all of the visits, which she told me was going to be $100 per visit.
I have questions about the legality of how the Therapist's office is handling the whole process, but for this forum my question is can the insurance company say a service is covered, make payments to the office in question, and then turn around months later and say it's not covered and pull the payments back. The coverage hasn't changed in over 2 years, so it's not a plan issue. According to the therapists office, the insurance company said they made a mistake is saying it was covered and sending payment checks to the therapist.
I looked through some other posts to try and find out what responsibilities an insurance company has, but didn't see anything quickly, although I'm going to continue looking. Thank s in advance for any insight, and please let me know if there's anything else I can provide that may help.
Larry
Answer
First of all, YOU should have been the one to contact your insurance to find out if treatment was covered before any treatments began. It is your contract with the insurance and it is your responsibility to know your own coverage. Insurance coverage is like snowflakes -- no two are exactly alike and the responsibility is yours to know what is covered before you incur a medical debt.
That being said, insurances go "back on their word" every day. Depending on your plan, some of them are very well known for doing just that. If you had called in advance, you should have taken down the name of the person with whom you spoke (first and last, if they'll give it; though sometimes they give phony names), the date and time of the call. It is possible the therapist acquired that, but then they would be doing your homework. Find out and press the issue with the insurance company.
It really shouldn't be an issue at all. What does your insurance handbook say? It should be clearly spelled out what is covered and what isn't. Is your provider In Network? Is it a covered diagnosis? Again, all things you should have found out prior to seeing any provider.
Ultimately, YOU received services for which the provider isn't being paid. You owe the therapist, as I am certain you signed paperwork on your first visit stating such. You can still try to get the insurance to pay, but whether they do or not doesn't absolve you from your obligation to pay the therapist. What if the insurance company had gone out of business since you were treated? Are you just going to tell the therapist that he/she is out of luck? Would you like that done to you?
See if you can begin a payment plan while you are wrestling with the insurance, because now the therapist has not been paid for your treatment for the past four months. If the insurance pays, the therapist can give you your money back.
If you are wondering about my qualifications, I have been teaching Medical Coding and Billing at a community college for years. It bothers me when people don't take responsibility for knowing their own insurance...but I absolutely HATE it when an insurance company gets away with something!
Answer
That was an excellent answer!
In addition to ajkroy's answer, I would like to ask whether OP is sure h/she had coverage during the actual dates of service. Did they leave their job or did their employer change coverage (even if it was with the same insurance company) at any time during the treatment period?
Answer
It is possible you need the therapist to change your diagnosis code to one covered by your insurance plan. Slight nuances in the DSM-IV contribute to having / not having coverage.
Answer
Well, I'm not sure I agree completely with you ajkroy. If ultimately, it's the customer's responsibility, then the doctor's office shouldn't offer to check, should they? And the fact the doctor's office checked vs. me, really isn't material to the question I asked, assuming the doctor's office isn't lying to me. I'm guessing you are coming from the provider side of the wall, so I guess I'm not too surprised by the tone of your answer. For all I know the doctor's office could just be committing fraud by telling me one thing and then after charges are rung up, telling me I'm responsible. But I'm assuming (for now) they are being honest.
We called the office to to find out if they took our insurance, but they said mental health benefits are tricky and said they would call and check for us, and they say they even received partial payment from the insurance company for a while, before the insurance company changed their mind on payment. So I don't think it's as simple as you are assuming it to be.
There is no way for me to check paperwork or with a provider to be sure that a visit will be covered, too many things change, which is why checking with the Insurance company seemed like the safest way, which is what happened. I'm wondering if there is any obligation on the part of the Insurance company once they say things are covered (assuming there's nothing the customer hid or did to invalidate it, and there were no changes to the plan or the provider), and if not, the health care system sucks worse than I thought, because you can never be sure something is covered and that you won't be liable for some significant addiitonal cost. I tried to do everything that I could, but I still get the shaft, and the Insruance company and the doctor's office don't shoulder any of the responsibility for their mistakes.
lealea1005 : No, there were no changes to the plan or coverage in the last few years, and no change in the provider's status. According to the provider, they called to verify coverage for the services, were told that they were covered by the Insurance Company, told us the covered price (and never told us what an uncovered office visit would cost), and then 4 months later the Insurance Company told them it wasn't covered, and they passed the charges on to us (and even more than they were going to get from the insurance company).
Answer
It IS only your responsibility, whether or not you agree with the answer. There are thousands of health insurance companies. Each company has hundreds of plans. The therapist's office tried to get the correct answer for you. They were even PAID by the insurance company. So, why wouldn't they think that you were not covered? But, according to your post, they called to inform you that the insurance company was going to reverse the payments. You are saying that is the fault of the therapist's office? NOT
However, YOU have a policy at your house which clearly states what is and isn't covered. It would have taken you minutes, at most, to verify coverage. It would have taken you less than 10 minutes to call customer service and verify coverage. You did neither.
They provided a service. You received a service. You are responsible for the payments being made. PERIOD. Again, whether you agree or not is irrelevant.
Answer
Well, I'll hope some else posts something more useful (and less condescending). You're basicaly saying the Insurance Company has no obligation to pay claims, regardless of what they tell you. And if that's true, then you are right I don't agree with it and right that it doesn't really matter. Plus, even you think you do know everything, you don't have to act like it.
Answer
Well, I'll hope some else posts something more useful (and less condescending). You're basicaly saying the Insurance Company has no obligation to pay claims, regardless of what they tell you. And if that's true, then you are right I don't agree with it and right that it doesn't really matter. Plus, even you think you do know everything, you don't have to act like it.
Ok, let me try this from the provider's point of view. I provide a service. The coverage of such service has been verified by my office staff. (Why are you assuming the Doctor's office is committing fraud?!?!?) The insurance company pays me. Four month later, the insurance company changes their mind and immediately takes their payments pack via a debit from another patient's payment.
The patient signs a section of their registration form in which they agree they are ultimately responsible for payment in full, should the insurance company decide not to cover the service.
Why do you feel it is OK for your Therapist to go without being paid for services h/she provided to you? Regardless of whether you liked any of the above answers offered to you free of charge from people with medical/insurance experience, the answers remain correct. You, the consumer, are ultimately responsible for reading your insurance information and getting benefit/coverage information from them. Your Therapist's office staff probably thought they were being helpful when they offered to verify your coverage.
This is a perfect example of how the insurance companies put the medical service providers at odds with their patients. Insurance companies are big businesses. They're main concern is their bottom line....making money. Despite all the flowery commercials, they really don't give a darn about you.
Answer
This is a perfect example of how the insurance companies put the medical service providers at odds with their patients.
This is a perfect example of how capitalist medicine is at odds with patient care and any rational understanding of consumer rights.
Don't worry, I really do believe your legal answer. I just hope the clinic gets stiffed, legal or not.
Good luck with that.
Write off and bad debts are part and parcel of capitalist business. The practice made a decision to treat based on insurance coverage.... if those payments are conditional or can be taken back... when thats just called the cost of doing business. Cry me a river for the business of medicine.
But then again I am the kind on person who refuses to give ID at the emergency room - for a sniffle - called asthma.
Answer
No, I understand you, and see where you are coming from (and agree with most of what you say). I'm fairly sure it's the Insurance Company at fault here. The office could have notified me earlier that they were having some problems getting full payments (which they said they were having) which would have caused me to wait and see how it could be resolved. And I'm not happy that they are charging me more per visit than what they were going to get from the Insrurance company. But by trying to be helpful, they have put me in a bad position. I can't even verify that they called and checked, since they called their provider line, and not the standard line. So by trying to be helpful, they've left me very little recourse since I can't ever verify what was said or not said. It may not be the way the law is, but by taking on the responsibility of verifying my coverage (which they offered to do, I just called to find out what plans they accept), it seems the "fair" thing to do would be to try and help me resolve it, but they are more interested in passing the charges (and then some) on to me. But I know fair isn't really what counts or matters.
But I still don't think I've gotten a good answer to my question (or maybe I've just missed it). Regardless of who it was that called to verify coverage, I'm wondering if an insurance company is called to check for coverage, and they say something is covered, are they under any obligation to fufill that coverage if it turns out their rep just made some kind of error on their side? Or can they just back charge you anytime over the next ten years for services that they made a mistake on.
(and thanks for your reply)
P.S. And to some of the other replys, if the insurance company's reps can't even get what is covered and not covered correct (which is what happened) you are "DELUDING" yourself if you think the customer can just look at their "insurance handbook" and check their "policy at your house". And if you are really interested in trying HELP people, and not just SHOW OFF, YOU have a better CHANCE of doing it ACTING more like lealea1005.
P.P.S. And I don't want to stiff the provider, but I also don't like paying for something that I couldn't have avoided, and while it may be legal, it just feels unfair the way they are handing it. I'm hoping to find a compramise that feels "fair" (which again, I know doesn't really mean anything, and is probably me expecting too much).
Answer
If you still want to go to the therapist, find out what your DSM-IV code is and what your score is. It is possible to have your therapist/Dr adjust your DSM-IV code and then your insurance would cover it.
For example (I don't have the DSM-IV code on me, but this is from personal experience in getting insurance to cover treatment), if you are seeking help for depression, make sure your DSM code is severe, reoccuring (whatever the threshold for insurance coverage). Insurance would cover it if you really needed it, and they base your need off the DSM code and ability score your therapist provides.
Not sure if this would help with the past bills, but it might.
Answer
This is a perfect example of how capitalist medicine is at odds with patient care and any rational understanding of consumer rights.
Don't worry, I really do believe your legal answer. I just hope the clinic gets stiffed, legal or not.
Good luck with that.
Write off and bad debts are part and parcel of capitalist business. The practice made a decision to treat based on insurance coverage.... if those payments are conditional or can be taken back... when thats just called the cost of doing business. Cry me a river for the business of medicine.
But then again I am the kind on person who refuses to give ID at the emergency room - for a sniffle - called asthma.
WOW!
Actually, unless it's an emergency, a practice makes the decision to treat based on whether the patient/consumer agrees to compensate the provider for the service, regardless of whether their insurance will cover the service. That's why they sign the agreement on their registration form.
There is no "write off". I cannot deduct the "loss" from my taxes. My livelyhood, as well as MY ability to pay my bills, is dependent upon patients paying me.
Answer
None of what I said to you was condescending. It was simply the truth. You, as a consumer, have the right and responsbility to know what's going on. Period. Let's say the doctor's office did verify coverage. Let's say she spoke to Sally. Let's say you call Sally and ask if the doctor's office called, and if Sally made a mistake. Let's say Sally said "I made a mistake".
Now:
1. Did you verify that what Sally said was true? Why not?
2. Did you look at your policy to make sure that the therapist was correct? Why not?
3. Did you sign a paper agreeing to be responsible for all bills? Why.
Answer
No, I understand you, and see where you are coming from (and agree with most of what you say). I'm fairly sure it's the Insurance Company at fault here. The office could have notified me earlier that they were having some problems getting full payments (which they said they were having) which would have caused me to wait and see how it could be resolved. And I'm not happy that they are charging me more per visit than what they were going to get from the Insrurance company.
Perhaps you can ask whether they would be willing to accept the fee that would have been paid to them by the insurance company.
But by trying to be helpful, they have put me in a bad position. I can't even verify that they called and checked, since they called their provider line, and not the standard line.
Providers are not permitted to call the "standard" line.
So by trying to be helpful, they've left me very little recourse since I can't ever verify what was said or not said. It may not be the way the law is, but by taking on the responsibility of verifying my coverage (which they offered to do, I just called to find out what plans they accept), it seems the "fair" thing to do would be to try and help me resolve it, but they are more interested in passing the charges (and then some) on to me. But I know fair isn't really what counts or matters.
But I still don't think I've gotten a good answer to my question (or maybe I've just missed it). Regardless of who it was that called to verify coverage, I'm wondering if an insurance company is called to check for coverage, and they say something is covered, are they under any obligation to fufill that coverage if it turns out their rep just made some kind of error on their side? Or can they just back charge you anytime over the next ten years for services that they made a mistake on.
I recently had payments from over two years ago reversed by an insurance company, and that was after getting verfication of coverage in writing before the patient's first visit. They just debited what they would have paid us for services for another patient, so they were paid back immediately. We now have to track down the patient and try to explain why they have to pay a bill for services over 2 years old.
(and thanks for your reply)
P.S. And to some of the other replys, if the insurance company's reps can't even get what is covered and not covered correct (which is what happened) you are "DELUDING" yourself if you think the customer can just look at their "insurance handbook" and check their "policy at your house". And if you are really interested in trying HELP people, and not just SHOW OFF, YOU have a better CHANCE of doing it ACTING more like lealea1005.
Thanks, but the people who answered your question are all very knowledgable about this kind of thing
P.P.S. And I don't want to stiff the provider, but I also don't like paying for something that I couldn't have avoided, and while it may be legal, it just feels unfair the way they are handing it. I'm hoping to find a compramise that feels "fair" (which again, I know doesn't really mean anything, and is probably me expecting too much).
Good luck to you.
Answer
WOW!
Actually, unless it's an emergency, a practice makes the decision to treat based on whether the patient/consumer agrees to compensate the provider for the service, regardless of whether their insurance will cover the service. That's why they sign the agreement on their registration form.
I never stated that I disagree with those set of facts as how it works.
I DO sincerely believe that the patient and the practice would have adopted a different approach to treatment or refused treatment if the coverage was not there. Sorry, but I just don't think you have been uninsured or desperately underinsured recently enough to appreciate that insured patients are cash cows and uninsured patients are pariahs.
Nothing about validity of the patient payment agreement changes how much that sucks to build a schedule and treatment arround being covered and then have that coverage pulled
There is no "write off". I cannot deduct the "loss" from my taxes. My livelyhood, as well as MY ability to pay my bills, is dependent upon patients paying me.
Well you try to change that law to make your losses detuctible, and I'll be working on socialized medicine.