Question
What is the name of your state? Texas
I recieved a copy of a letter sent to my Endocrinologist, stating they overpaid him for every vist since June 2004 !!
The reason stated was :After review, it is determined these payments are not covered.." . What the heck is this about ?
Will I be responsible for this ?
Have they decided after 2 years that my medical care for hormome deficiency is no longer payable, and want all payments made on this repaid ?
I'm frankly scared.
Any help will be appreciated .
Joannie
Answer
There is not enough info to make that determination from here.
At face value it does sound as if you MAY be liable for the payments.
Have you recieved anything from your ins.co. about this?
Answer
This is common practice nowadays its up to the insured to verify that payment has been made. If your able read your health contract on whats covered or isnt**************......then if you have ammo duke it out with them like I did with the conglomerate known as PACIFICARE. Also your state board of insurance will help you.
Answer
I am going to check with benefits Monday at work on this of course, AND my doctor.
I am curious about a couple things :
1) Why they paid the doctor OVER and OVER again, every time verifying coverage and then paying the claim after initial review. It seems if there was a problem with the coverage,, they would not pay the claim, OVER and OVER again. That's why (of course) I assumed my care was covered. DUH
2) What prompted the to all of a sudden these payments made, then deny coverage retroactively ? Why now ?
I have not recieved anything from the insurance company on this - yet . The letter I recieved was a copy of a payment request sent to my doctor.
This seems VERY strange to me.
Thanks for the feedback and taking the time to offer it.
Joannie
Answer
I personally have experienced where an "in network" provider has been reimbursed $0 for a procedure. It is within the agreement between the doc and the ins. co.. That does not mean this is your case but with no additional info, this is one situation where something similar could happen.
As far as 2 years. Seems like a long time to get things straightened around.
I have seen similar things happen where the ins. co. tried multiple times to get additional info fromthe provider and the ins. co. actually paid these in anticipation of recieving the info. Maybe something like that here. When the additional info did mot show up, they gave up afeter a point and said heck with it.
Good idea, check with the ins. co.. they be the best to talk to.
Answer
There is no contractual relationship between the provider and the carrier. There is a contract between the provider and the MCO (managed care organization), a contract between the MCO and the carrier, and a contract between the carrier and the insured.
If the carrier refuses to pay (or demands and gets a refund for monies paid) then you will be responsible for payment.
Carrier audits are routinely done and this one may have been caught during such an audit. If a claim is denied (or retracted) the carrier owes you an explanation. When you get that information you will know which direction to go. Until then you are in the dark.
Answer
If the physician refunds the carrier, expect them to bill you.
You may be able to negotiate a discount for the really old claims.
You will have to speak with the billing manager.
Answer
There is no contractual relationship between the provider and the carrier. QUOTE]
And how do you arrive at this conclusion?
When I spoke with my insurance company and they told me they have a contract with the provider, I presumed they meant the have a contract "with the provider". That is usually why they make that type of statement.
Answer
There is no contractual relationship between the provider and the carrier. QUOTE]
And how do you arrive at this conclusion?
When I spoke with my insurance company and they told me they have a contract with the provider, I presumed they meant the have a contract "with the provider". That is usually why they make that type of statement.
My thoughts exactly when I saw that.
There is a contract between carrier and provider AND between carrier and patient.
The provider/carrier contract states along the lines of, you do this, and we'll pay this - you accept $X as payment in full, minus applicable patient copay due