Question
I am in AZ and the insurer is Cigna PPO.
I was directed by my primary physician to physical therapy for back bain. No MRI allowed until therapy attempt according to insurance. Physican referred to Phys therapist, and when completing registration, the therapy office staff stated I was responsible for my copay but my insurance covered everything else.
7 visits later, I received a statement from my ins co. I owe over $500 to the therapist above my 280.00 copays! Apparently The therapist office is "out of network so not covered."
I believe the therapist should be responsible since they confirmed insurance coverage prior to 1st treatment.
What to do? Help?
Answer
I believe the therapist should be responsible since they confirmed insurance coverage prior to 1st treatment.
That is not correct. Your insurance is YOUR responsibility alone. The therapist bears no responsibility in this whatsoever. You are responsible for the bill.
Check your policy to see if you can recoup partial payment for the out of network service you received.
Answer
OK, lets say I have the responsibility for payment. I don't agree since the provider told me one thing and then is changing the rules after treating me for 3 weeks. I am going to try to negotiate with them but would like more advice on a couple points.
So, My insurance is sucky and only covered about 100 bucks as out of network services. Since I have paid 240.00 in "Copays", I would hope that I am able to apply that money toward the total charges if I just ask the provider to bill me direct w/o insurance. It seems to me a COPAY is really not an actual part of the bill, but rather an access fee of sorts.
For example, this 40.00 per visit copay does not go towards the services rendered, but rather is a premium that members pay to access the provider service.
I hope to negotiate a better rate and use the copayments as part of the total charges. Man y providers give better prices to cash paying customers if they do not have to deal with the insurance company.
Thoughts?
Answer
lets say I have the responsibility for payment
There is no question about this. You received services. Your carrier paid their contractual obligation. You are responsible.
I don't agree since the provider told me one thing and then is changing the rules
What rules did your provider change? Did your provider change the insurance contract or carrier? Did the provider change your network eligibility?
You are free to negotiate with your carrier or the provider. Neither is obligated to alter their position.
It seems to me a COPAY is really not an actual part of the bill, but rather an access fee of sorts.
No, your copay is part of your financial obligation when services are rendered. The copay does go to the provider, not the carrier, so part of your argument holds true in that, your bill is reduced by what you have paid + what the carrier has paid.
Anything beyond that is wishful thinking on your part.
Answer
Who dude.... Don't rip my head off. I was asking for advice, not for belittlement. When presented with a position, I questioned it. Not like a little lemming who blindly drinks the magic koolaid following one person's idea.
I had a question and an opinion and presented them. I am not a Lawyah and was seeking other opinions from those who might know more. Looks like I found somarco... who knows it all!
Maybe you should check with your own Dr and get that Blood Pressure checked. Even from here I can see that big Vein in your head bulging out!
Answer
Please accept my apology . . . it was insensitive of me not to take into account your back pain which excuses you from any liability for payment.
Your provider should be more sensitive as well since it was THEIR fault for not checking YOUR policy to determine which network serviced your particular account. The employees of the provider will understand too when their paychecks come up short because your carrier did not pay as much as you wanted them to pay. After all, someone has to make up for "their" error.
The provider should have realized someone in your condition is unable to check their policy or call their carrier before committing to treatment. The provider has nothing better to do than to take time out before each appointment is set to call and determine who will be paying their bill.
And your carrier is just as much to blame for not calling you to make sure you understood who were network providers, and who weren't.
Gosh, now that I look at this again, you are completely in the right and I was wrong. This certainly isn't your fault.
Someone as understanding as you will have no problem when your employer shorts your paycheck because some of their accounts neglected to pay. Eventually you will get paid, so don't sweat it.
That's the way life is in your world.
Answer
Somarco...
So you are saying that as examples,
If I as a small business consultant, need clarification of law. An I ask an IRS agent to verify, that what I am wanting to do financially for a client is legal,(forget ethical)that it is not their responsibility to give me good information...
Or if I go to a Dr. it is not their responsibility to give me an accuarate diagnosis, and an accurate bill?
Or if I go to the Garage with my car, it is not reasonable to expect an accurate diagnosis and fair estimate of charges for the repair? And I should expect to pay 3 times the original estimate without questioning them?
I take issue with individuals and companies who tell you one thing, and then try to change the story when they screw up.
In this case, the therapist told us in no uncertain terms that they contacted my insurer and we were covered with only our copay. WHY WOULD I DOUBT THAT!
I have decided to stop feeding the Troll now. (somarco)
Answer
...but your doctor did give you the healthcare service and an accurate bill. Thus ends his/her responsibility toward you. Then you are responsible for making sure payment is made. Whether or not you personally pay the bill or get a 3rd party (your insurer) to pay it is your business, not your doctor's.
It is always the policyholder's full responsibility to understand, interpret, and choose to comply/not comply with the policy's terms. You may wish the healthcare provider is responsible for doing that, but it is simply not the case. Healthcare providers have NO responsibility in that regard (unless we're talking about Medicare insurance). I know that's not what you want to hear, but it's the truth.
Your analogy of the IRS agent does not match the situation with your physician. It would be correct if you said you asked a plumber for tax advice, followed it, later found out the advice was erroneous, and now are wanting the plumber to pay the fine.
Answer
Thx purple, for explaining this in more detail.
Answer
No problem.
The OP's confusion about who is responsible for knowing insurance coverage is quite common. People simply do not realize it's their responsibility, even though that is spelled out in their insurance policies.
This scenario is why I always advise registration clerks not to tell anyone about their insurance coverage (except Medicare)....it's best to just say, "We will bill any insurer as a courtesy to you, but we cannot advise you as to what they will pay or not pay. It is best for you to check your insurance policy or call the insurer directly."
I always love it when patients say, "You SHOULD know all about what my insurance coverage because I have Blue Cross."....uh, yeah, and I've memorized several thousand different BC plans.....
Answer
Purple -
This case is like many, the contract with the carrier does not appear to be the issue here. It seems to be an issue of not clarifying which PPO contract is in place, or if the provider(s) are in network or not.
Providers move in and out of networks with frequency. Employers will change plans (and in turn PPO networks) almost on an annual basis.
The best way to maximize benefits is for the insured to read their contract, and ask the CARRIER (not the provider) if a procedure or provider is in network.
Almost no one does that and then wants to blame everyone but themselves for the ensuing problems.
Answer
Look, at time of service, you probably signed a piece of paper guaranteeing the physician payment after your insurance processes the claim.
Therefore, you are liable to pay the out of network physician. End of story.
Next time, you will check - call the carrier and ASK - is Dr. Smith in network.
Answer
I am in FL. Unfortunately, they should have told you that they were not in network with your insurance company, however, it is your responsibility to check which providers are in your network. The primary care physicians office (usually the referral coordinator) should have also had a list of providers for Cigna in which to send you to for physical therapy that were in your network. Are you in a isolated area where there may not be many physical therapists within 25 miles of your home? IF so, then that may be a case for you to build upon.
Again, unfortunately, I believe that you are stuck with the bill unless there are laws in your state prohibiting this act.
Answer
You (FWIW) seem to be having a lot of fun here, telling folks they are not responsible for paying their provider. You also are putting quite a bit of this back on the provider, who is not party to the insurance contract.
The policy is between the insured (individual or employer) and the carrier. Providers are never a named party in these agreements.
I find it curious that you want to pass responsibility to someone who is merely a payee, and then only by assignment.
You remind me a great deal of an attorney I was affliated with many years ago who was great at bluffing but had very little substance when forced to deal with the facts. Is that you, Al?
Answer
It is extremely rare for an insured to ask if a provider participates in a particular network (which is really the crux of the issue here). More often than not the wrong question is posed (do you accept XYZ insurance company for assignment) to which the response is usually in the affirmative.
Some carriers use multiple networks. It is possible for a provider to accept XYZ and participate in network L but not network T which are both recognized by the carrier.
I think it is a real stretch to presume the provider is willingly misleading the patient in an attempt to get the patient to use their services. The provider is much better off, more times than not, to have their bill paid by a third party (even at discounted rates) rather than relying on the patient to come through.
If you are not Al, you are his clone.