Question
What is the name of your state? Illinois
When visiting relatives in Virginia in August this year, our son became ill. We took him to a nearby doctor's office that was supported by our insurance, only to find that they would not accept insurance from out-of-town patients.
However, they would still treat him providing that we paid the fee of $125 at the time of the appointment, whether or not we had insurance.
After doing so and after the appointment, we were actually given a bill of $259. When asked why the bill was now $259 rather than the previously agreed $125, they simply said, "Don't worry about that, you are all set."
Upon our return back home in IL, we obtained the necessary forms and filed the insurance claim, clearly requesting that the payment be sent to our address. However, on September 12, the insurance company sent $92.47 to the doctor anyway.
Now, the doctor has kept some of the money. And we faxed the doctor, requesting a suitable refund. Not receiving an answer, we followed up with a phone call. After Three calls, they told us something about being able to keep the money.
My questions are:
1. since we had (before the appointment) a verbal contract of a $125 same-day price, now he kept $164 which is more than the insurance allowed; is that legal?
2.Another thought is that since the doctor originally said that he would not accept out-of-state insurance to begin with, why could he have taken any at all, when the insurance company mistakenly sent the payment to him?
3. The insurance company sent the check to the doctor even though we
requested it to be sent to us. The emotional, time, and long distance
phone bill costs have been high for us (We faxed the document to the
doctor and called them three times, they never return our calls). Who
could we complain to about the insurance company?
4. I think the doctor should honor this agreement and refund the $92.47 to us. We will then keep $75 and return the balance to the insurance company
(according to our plan, we should be paying 40% of $125 which is $50, but since we've already paid $125 we should get $75 back.)
Thank you very much for your advice!!
Answer
Doctors don't make agreements on price--They can't--They have to bill everyone the same according to the services that are rendered, else it would be discrimination. Often the office staff may not communicate properly their procedures for billing.
It is standard to make new patients/out of town/not networked insurance patients pay a standard fee. The fee is usually established on the average charge for a new patient office visit. If you had other services, ie, pulse ox, nebulizer, splints, wound dressing....a whole number of things, that would adjust the price accordingly. Until the doctor actually sees the patient, he/she can't know what is needed.
Insurance companies often send the payments directly to the medical provider, even if you requested otherwise. If your total bill was $259 and you paid $125 + insurance of $97, there may be a balance on the account, unless the provider is obligated by contract to write off any of that amount.
I would request a copy of your account statement, so you can see exactly how the money was applied. If there is a patient credit, you are due that amount. They may require you to request the copies in writing (HIPAA).
If you have a legitimate complaint about your insurance company, write to the Insurance Commission or go to their website, they may have some sort of form to complete for details. It also wouldn't hurt to send a complaint letter in writing to the management of the medical practice, and tell them of your concerns about what you were led to believe about their pricing/billing. They may have an employee who doesn't understand, etc.
Good Luck--