Posted by fallsfall on March 15, 2005, at 11:30:49
In reply to More money stuff :(, posted by All Done on March 15, 2005, at 10:17:53
I'm so sorry, AllDone. I have been through similar insurance nightmares recently. This is what I've learned:
If a doctor is a provider for a particular insurance, they often have agreed to accept the insurance's "Maximum allowable" fee (in your case, $72). This seems to be the case for you (since the insurance lady said what she did). So, according to the contract with the insurance company, he is *not* allowed to charge you the difference between their Maximum allowable fee and the fee that he chooses to charge - so he is supposed to be writing off the $18. His contract with the insurance company may also require him to submit the claims (and only collect your copayment at the time of service). If these things are stipulated in his contract with the insurance company, then having you pay upfront and having you pay the extra $18 is in violation of his contract. That said, though, the contract is between your doctor and the insurance company - so your doctor may choose to apply his own scruples in deciding how to act. You may have leverage as a customer of the insurance company to force him to follow the rules of the contract (but somehow, forcing my therapist in this way didn't seem like a good way to maintain a good patient-therapist relationship...).
Your therapist may decide that he doesn't want to be a provider for your insurance because he doesn't like those rules (this is what mine does). That doesn't necessarily mean that you can't have your insurance pay part of his fee. It depends on what kind of insurance you have. There are some insurance plans that ONLY pay if you see "their" doctors. But many of the insurance plans that have doctors who sign up as "preferred providers" will also pay claims with "out of network providers".
In my case, my doctor charges $150 and is not a preferred provider. My insurance company's maximum allowable fee is $70.50. I submit the $150 bill to them and they pay me 80% of $70.50 (because they pay 80% of their maximum allowable fee for out of network providers). I own the rest of the bill.
My previous insurance was much better. Same doctor, same fee, still an out of network provider, they paid me 80% of his fee (i.e. $120). They said that since he wasn't a preferred provider that he hadn't agreed to the maximum allowable fee, and so they paid 80% of the fee that he charges.
The really interesting part is that these are the same insurance company (just branches from different states) - one from my former employer, the other from my husband's employer. So either the insurance company sold very different policies to my employer and my husband's employer, or the different state organizations have different rules.
It seems to be virtually impossible to find out what the maximum allowable fee is until you submit a claim. I asked my current company twice what the fee should be and was told both $137 and $112.50. The correct amount is $70.50. I have no idea where the other numbers came from (except that they came from people at the insurance company). They would not "guarantee" those numbers - they said they were "estimates". Somehow, being off by almost a factor of 2 didn't sit well with me for an "estimate"... Don't get me started on this!!!
My therapist is flexible in that he lets me pay my portion of the bill at time of service and he waits for the rest until my insurance company pays me. But I know that if there is a problem with the insurance company that I will still owe him the balance. This is a policy that he has chosen - he could choose to have me pay up front and be responsible for the float myself.
Since your therapist just switched to private practice, he may not know much about insurance. And you may end up being one of the test cases where he learns what he needs to know... Sorry.
Let me know if you want to talk more about this in a less public forum...
poster:fallsfall
thread:471253
URL: http://www.dr-bob.org/babble/psycho/20050315/msgs/471280.html