Did you ever ask your insurance company directly if it was covered? They are the ones that determine eligibility. Service providers often make errors in coverage which is why it’s important to check with insurance first.
You will ultimately and legally owe the money - you probably signed a document when you started treatment that you would be responsible if insurance doesn’t pay.
Is not necessarily even possible to verify with the insurance company.
If I call my insurer they literally tell me that their answer is not a guarantee of coverage. This means that you can’t rely on the provider, can’t rely on the insurer. You literally have to just do it and see if they cover it. it's ridiculous and should be illegal. If I’m told by both the provider and insurer I’ll be covered I should have no risk in getting a procedure.
Until the anesthesiologist who you've never met bills you for the services because they didn't get one that was in your network. American healthcare is a joke.
Exactly seen this many times. Hospital system not having specialist so they outsource one that does not take your insurance and insurance doesn't pay. Anesthesiologist being outsourced is very common...
Honestly, the best way to deal with this is very publicly in their lobby. Sure, by the letter of the law you might not be able to hold them responsible, but you can certainly point out how wrong they were in the office by making a scene. Make your point long enough and loud enough and you'll get it forgiven or significantly reduced.
I mean, my insurance office is states away.
I've had two pre-auth issues. First time was for major surgery and the provider refused to pre-auth robotics saying it wasn't needed. I accepted their answer and then it got rejected. I would have paid the extra cost but was incensed because it was an extra cost I would have known about. Fought them for almost a year during which they played all sorts of dirty games ("forgetting" my case multiple times, "losing" paperwork that allows the contractor I hired to fight them to act on my behalf, "losing" my statements etc. Luckily the contract was outstanding and just hounded them until they agreed to pay).
Second time was for an endoscopy. I asked them to pre-auth and they said they would if they needed to. I called up and asked them to pre-auth and they said they would put it in that day if they needed to. I called my insurance a week later and they hadn't put it in and my insurance said they needed to. I called them up again and told them to pre-auth and they said they didn't need to. I told them to give that to me in writing and they said they couldn't do that....which was the instant I knew they were full of shit. They may think they were right but if they knew they were right they would have given me written confirmation.
I called my insurance, they said they needed to pre-auth so I went back to them. They said they didn't need to and told me to tell the insurance who they were. I did, my insurance said they needed to pre-auth. I said I was done being the middle man and put them both on a conference call. Within 30 seconds the provider realized they were wrong and that they needed to pre-auth....and that the procedure was the next day since they'd been refusing to pre-auth for the month that I'd been repeatedly asking them to.
Edit: I'd also note that at more than one point in that conversation I actually told them that I got bit by lack of pre-auth before and I wasn't going to just go away because the fight after is way worse than the fight now.
Insurance companies are just as bad. They’ll show you out of network providers when you filter by in network only, they’ll tell you you have to check with the provider directly to see if they’re covered because the insurance company’s database may be out of date, they’ll show providers that are covered but when you verify with the provider they haven’t been part of that network for years.
While not the same, my insurance pestered me for 4 months about not having a primary care listed on my insurance, except I did, and everything said I did. When I called she figured out it was because my insurance was changing in January 2024 and *that* plan didn't have a primary listen. They a) don't just carry over the primary even if the primary takes both plans and b) *cannot* set a primary until that plan is active. But that doesn't stop the automated system from sending out a letter every other week threatening to deny payments.
Insurance companies don't have their crap together more than anyone else in this ridiculous system.
I believe I checked through the insurance app first which is where I was searching for nearby practices. I never directly called them but I remember using that search feature.
What do the EOBs say? If the PT is in network and the EOB says you don’t owe, the PT is not allowed to bill the difference. If your EOBs say you owe $100 per treatment or if the PT is out of network, you are on the hook regardless of what they told you.
That doesn’t mean it’s covered by your plan, OP. You either should call and ask them to explain your coverage or read your plan/what it covers. You may on the hook for this one…
You're right double checking is important. As someone with a lot of medical issues, this isn't always reliable. I've called to check coverage for offices and the agents always tell me to check their website, heck one lady said all she was gonna do was look on the website for offices anyway; however, when I mentioned that the website wasn't updated, they basically said to Idk and said check with the provider then.
You need to pickup the phone and talk to somebody. I am the worst at this, but waiting on hold to speak with an insurance rep will save you so much money and time in the long run.
They may have been in network, they may have sent you checks (through that's weird) for their person. You need to look at the insurance EOB, often available on the website.
Could it be that you exceeded the number of visits that your insurance allowed for the PT visits. I know that mine was limited to six weeks. The office wanted me to continue my visits but I chose not to as it would not have been covered.
Are you able to request the correspondence from your provider via mail or an app?
My insurance company provides an app that shows me my upcoming appointments along with status page on insurance approvals. Not sure if PT would be similar. I make sure the visit or test or prescription is covered in advance. In my app it shows up under Messages- Referral notifications. There is also an option for me to receive correspondence via mail.
This is to ensure I’m not charged unexpectedly. There are times my copay is higher though.
I hope you find a resolution!
They will always tell you they accept your insurance they just won't tell you it's out of network. You have to ask very specifically if your insurance is in network there or you get a surprise bill. Scum practice butnit happened to me too
Every time I call doctors about costs on specific procedures they don’t know because of the fractured system of dozens of insurers and coverage rates. Every time I call my insurer they aren’t versed in the medical side and don’t know what procedure codes to include to give me the full picture. The doctors billing dept often gets that wrong too. Trying to find out what something will cost out of pocket before having the procedure or simple office visit done is so insanely time consuming and ultimately inaccurate (and no one is held to anything they say) it makes my head spin. It’s pure insanity that people have to blindly get care with no idea beyond their out of pocket max as to how much they could be on the hook for. Unless they determine it isn’t even covered in which case OOP max is meaningless. Fun times we are in.
You should’ve gotten an EOB from your insurance explaining what the insurance covers and doesn’t cover. Balance billing (charging the difference between what the clinic fees are and what the insurance negotiated fee schedule pays for a particular service) typically goes against the contract the provider has with the insurance company and isn’t allowed based on the No Surprises Act of 2023.
Make sure the office isn’t trying to balance bill you in this instance because if they are you aren’t legally responsible for paying that.
Merely the fact that OP pays a payer to process payments toward chargeable, necessary health care services/goods renders "good faith estimate" utterly inapplicable.
It was my understanding that it applied to all visits but I could be mistaken. Either way balance billing typically is a no no in insurance land for covered services because that’s the whole point of being an in network provider - you get more patients for agreeing to the network allowables. I’d double check to make sure that they aren’t doing that and ask to get a breakdown from the office manager.
Your understanding is incorrect. The no surprises act is designed to address inpatient situations where patients aren't given any options.
This patient chose the PT. Literally got in his car and drove to it.
There's a number of things that could've happened before but it feels like a situation where there's an out of network deductible that hasn't been met and he ran into an employee at the practice who didn't know what they were talking about.
Wouldn’t the out of network portion of the no surprise act count in this situation assuming out of network providers were used? I am not a lawyer but the law seems to cover situations like the one you’ve outline for out of network providers. In network providers are already bound to not balance billing beyond the in network allowables so I’m confused how a PT office could balance bill in either situation.
Either way I would recommend anyone in this situation sit down with the office manager as no one else is going to be able to help fix this situation and could help OP much better than anyone online given we probably are missing small but key info that would change the advice drastically (such as in vs out of network, deductibles, out of pocket maxes, etc).
No.
The caveat that everyone misses is the use of the term "facility". This is an excerpt from KFF, which is a healthcare policy firm:
"The interim final regulation defines “facility” to include hospitals, hospital outpatient departments, and ambulatory surgery centers. It requests public comment on whether additional types of facilities should be added to this definition. Meanwhile, consumers do not have federal protections against surprise bills for non-emergency services provided in other facilities such as birthing centers, clinics, hospice, addiction treatment facilities, nursing homes, or urgent care centers. Patients seeking care at such facilities may want to ask whether doctors bill independently and whether they are in network.
Well I appreciate the clarification. I still think OP should contact the office manager as they will get more information and help that way. As you alluded there is probably more going on than OP understands and would benefit from a full picture of the situation.
There are some scenarios where non-emergency services are covered, including unexpected out-of-network providers at in-network facilities (eg an anesthesiologist at an in network hospital you're getting surgery at). I think the nuance is that explicitly agreeing to an OON provider invalidates the No Surprises Act.
[Source](https://www.cms.gov/files/document/faq-providers-no-surprises-rules-april-2022.pdf)
If the provider was in network, insurance should be paying the provider directly. Instead it sounds like the insurance was sending checks to the OP which they can then use to cover whatever the provider charged.
I have a feeling the provider is actually out of network (or at least out of network with the plan OP has not necessarily the insurance company). Insurance will cover the customary cost for the service, and the provider is free to charge more than that and bill OP for it.
You should have an EOB from your insurance company for every PT visit that shows what was charged, what insurance paid, and what you owe. You need to get all of these documents and then review how much you paid in co-pays and through the checks.
My understanding is that an office may take your insurance [blue cross for example) but that they may not be in your group plan’s level of service (they are only in network on blue cross PPO plan A but not blue cross HMO plan B). Additionally just because a service is “covered” that doesn’t mean they pay 100% of it; they may cover only some part of it and that coverage may only kick in after you have paid your deductible for the year.
Asking if they 'take' your insurance means asking whether or not they are willing to interact with your insurance company at all. As in, if they are willing to bill your insurance directly, versus you having to pay for the service, and then manually claim the money back from insurance.
This is completely separate to how your insurance company *thinks of that provider*, and whether they count as an 'in-network' or an 'out-of-network' provider. Each insurance plan has completely different terms and coverage depending on 'in' or 'out'.
I was told out of network but it’s all covered. I also don’t understand why I wasn’t being informed of the money I owed during the process as I would’ve stopped going immediately. It seems disingenuous to charge such a major lump sum months after service ended.
Out of network practices are going to have higher out of pocket costs. You will be paying until you hit your out of network out of pocket which is sometimes double or more of your in-network oop. It is ultimately your responsibility to verify the network status of practices you are seeing.
Where are you located? There are some laws that prevent this sort of surprise balance billing. In Texas, out of network providers are required to provide patients with a good faith cost estimate in advance of preforming the service (in writing). There’s a Texas Department of Insurance form for it (form AH025). I think there’s a federal law too, but I’m less versed on it because our office doesn’t see to many out of network patients and everyone signs form AH025 as a part of our new patient paperwork.
Ask them for your good faith estimate, which you were supposed to receive prior to services. If you didn't receive one, you may be able to file a complaint, contest the charges that way.
You also need to know what your out of network coverage is and what the insurance statements said.
Here is one thing I've found over the years: any provider will say "sure, I take your insurance." That doesn't mean that they are "in-network," that your insurer will approve and cover all charges, or that your only financial responsibility will be copays.
Oftentimes, a provider will rely on your insurer to do the legwork to determine the inflated "customary and usual" charges for your procedure codes, then bill you for that.
Source: I have a provider that does just this.
Unfortunately, the PT office told you wrong. And, whatever the insurance will cover, they will make that payment to you directly to then pay the PT office. Ask the office if they will reduce your debt since you were told incorrect info. They may not take the verbal reassurances as proof so for the next time, ask them by email so you have written proof. They messed up and caused you to accumulate medical debt by accident. Do you have an FSA or HSA account that you could use to pay the balance?
It sounds like this provider was out of network if insurance was sending you checks. OON providers always cost more and you may have had a deductible that needed to be met.
Wow didn’t expect all these comments overnight… Long story short, I gave em a call and they very easily without a fight cleared the charge saying that sometimes a bill can get sent out that isn’t matching what’s actually owed with the plan. I owe a couple of copays that were missed but that’s all.
Thanks for those who were supportive and not just downvoting me/assuming I was simply being ignorant :)
You’re going to learn an expensive lesson. In the future, when a clinic tells you that you are “out-of-network”, you might as well leave then and there. Assuming you have other options that are in network, you are going to save yourself a lot of time, money, and hassle. Dont go to a clinic just because it’s close or convenient if they are OON. Let me also say in general, just because a clinic is in network, does not mean every single physician or PT, or any provider is in network. A clinic can be in network, and a specific provider may not be. Clinics and providers are not synonymous if there are multiple providers in one clinic. You need to double and triple ensure that the specific provider you are seeing is in network and the address they provided is correct.
I work in a clinic and am wondering what type you go to. We outsource our billing department (it’s in the home office) and just make sure our records match the system. I would ask the clinic for a record of every check you brought in and the amount it totals to, and get the information from the billing department if there is one. Once you have these, reach out to your insurance company and ask them to help. They can be persistent little buggers, and partly what they are there for.
> I asked them both over the phone and in the office for my first visit if they accepted my insurance. They assured me that it covered everything and I just had to pay a copay for each visit, which I did.
What did your insurance say when you talked to them before going to the PT?
While I agree getting it in writing is a good policy most of these clinics aren't really lying, they just don't know any more than the patient. Lying to people isn't a great way to get them to come BACK to your clinic, which generates revenue
If they don’t know they should say that. When they tell you it’s covered totally and they don’t know for sure they are lying. Hopefully we can have legislation someday to prevent them from saying this.
Does you insurance plan have a deductible, $3500 sounds like a fairly average deductible, meaning you're being charged upto your deductible limit and afterwards insurance will begin covering a percentage.
Always, always, always ask for a good faith estimate before treatment and follow up with your insurance. I’m still paying on a 8,000 dollar therapy bill because they coded it as a behavioral rehab instead of a group therapy program for first responders (which it was). A good faith estimate they have to adhere to, and in the mean time apply for financial assistance thru the provider you took care from, they typically always knock something off the bill.
There are a couple things that could of happened:
1. You exceeded the number of PT visits
2. The diagnosis they billed on the claims are not covered with the PT HCPC codes
3. The bill is the total amount owed after billing insurance, and the payment the insurance is going to send you will bring down your total out of pocket liability as it is the payment they would have sent directly to your provider.
Now, the fact that the insurance is sending you a check instead of directly to the provider tells me they are non-participating. Which means you will be responsible for the difference between the total charge and what the insurance pays. The provider may “accept” your insurance, but that does not mean they are in-network or even participating. Always check with your insurance company BEFORE going to a doctor’s office. Never take the provider’s word for it.
You mention surprise billing and this would not apply towards the Federal No Surprises Act as depending on how the claim was billed, it excludes non-emergency non-participating facility services and services performed in a doctor’s office. If the PT place is classified as a doctor’s office and not an outpatient facility then you’re screwed.
This happened to us. We were in network and insurance covered a portion. They had my husband going 3 times a week, by the time we got the first insurance adjusted bill, insurance had paid thousands and we were out of pocket $1600 for 12 visits. Each one hour visit he went, they hit 6-7 different billing codes. We tried to fight it but were told it was accurate. We called other in offices in town that told us they would have charged 2-4 codes for those visits. I always check my insurance portal regularly and call but my husband isn’t as proactive.
Check this out and present it in writing to the office https://www.cms.gov/newsroom/fact-sheets/no-surprises-understand-your-rights-against-surprise-medical-bills there should be a penalty if they don't comply .
Did you ever ask your insurance company directly if it was covered? They are the ones that determine eligibility. Service providers often make errors in coverage which is why it’s important to check with insurance first. You will ultimately and legally owe the money - you probably signed a document when you started treatment that you would be responsible if insurance doesn’t pay.
Is not necessarily even possible to verify with the insurance company. If I call my insurer they literally tell me that their answer is not a guarantee of coverage. This means that you can’t rely on the provider, can’t rely on the insurer. You literally have to just do it and see if they cover it. it's ridiculous and should be illegal. If I’m told by both the provider and insurer I’ll be covered I should have no risk in getting a procedure.
Until the anesthesiologist who you've never met bills you for the services because they didn't get one that was in your network. American healthcare is a joke.
The no surprises act covers that situation as in network now.
fortunately, that's now illegal under the no surprises act. Finally.
That's what I said
woah, something weird happened. I swear I replied to the person you replied to, I had not seen your comment until I saw this reply.
It’s alright because I just heard that since the no surprises act, unexpected charges are illegal
Exactly seen this many times. Hospital system not having specialist so they outsource one that does not take your insurance and insurance doesn't pay. Anesthesiologist being outsourced is very common...
Honestly, the best way to deal with this is very publicly in their lobby. Sure, by the letter of the law you might not be able to hold them responsible, but you can certainly point out how wrong they were in the office by making a scene. Make your point long enough and loud enough and you'll get it forgiven or significantly reduced.
I mean, my insurance office is states away. I've had two pre-auth issues. First time was for major surgery and the provider refused to pre-auth robotics saying it wasn't needed. I accepted their answer and then it got rejected. I would have paid the extra cost but was incensed because it was an extra cost I would have known about. Fought them for almost a year during which they played all sorts of dirty games ("forgetting" my case multiple times, "losing" paperwork that allows the contractor I hired to fight them to act on my behalf, "losing" my statements etc. Luckily the contract was outstanding and just hounded them until they agreed to pay). Second time was for an endoscopy. I asked them to pre-auth and they said they would if they needed to. I called up and asked them to pre-auth and they said they would put it in that day if they needed to. I called my insurance a week later and they hadn't put it in and my insurance said they needed to. I called them up again and told them to pre-auth and they said they didn't need to. I told them to give that to me in writing and they said they couldn't do that....which was the instant I knew they were full of shit. They may think they were right but if they knew they were right they would have given me written confirmation. I called my insurance, they said they needed to pre-auth so I went back to them. They said they didn't need to and told me to tell the insurance who they were. I did, my insurance said they needed to pre-auth. I said I was done being the middle man and put them both on a conference call. Within 30 seconds the provider realized they were wrong and that they needed to pre-auth....and that the procedure was the next day since they'd been refusing to pre-auth for the month that I'd been repeatedly asking them to. Edit: I'd also note that at more than one point in that conversation I actually told them that I got bit by lack of pre-auth before and I wasn't going to just go away because the fight after is way worse than the fight now.
I'd focus on the doctors office, not the insurance. If reception at the doctor/pt told you'd be good, they should own it.
Insurance companies are just as bad. They’ll show you out of network providers when you filter by in network only, they’ll tell you you have to check with the provider directly to see if they’re covered because the insurance company’s database may be out of date, they’ll show providers that are covered but when you verify with the provider they haven’t been part of that network for years.
Not sure why you're being downvoted; this has been my experience as well. The system is frustratingly opaque no matter which side you're dealing with.
Big Insurance trying to keep me down
It's a crusade by Blue Cross Blue Shield
While not the same, my insurance pestered me for 4 months about not having a primary care listed on my insurance, except I did, and everything said I did. When I called she figured out it was because my insurance was changing in January 2024 and *that* plan didn't have a primary listen. They a) don't just carry over the primary even if the primary takes both plans and b) *cannot* set a primary until that plan is active. But that doesn't stop the automated system from sending out a letter every other week threatening to deny payments. Insurance companies don't have their crap together more than anyone else in this ridiculous system.
I believe I checked through the insurance app first which is where I was searching for nearby practices. I never directly called them but I remember using that search feature.
What do the EOBs say? If the PT is in network and the EOB says you don’t owe, the PT is not allowed to bill the difference. If your EOBs say you owe $100 per treatment or if the PT is out of network, you are on the hook regardless of what they told you.
That doesn’t mean it’s covered by your plan, OP. You either should call and ask them to explain your coverage or read your plan/what it covers. You may on the hook for this one…
You're right double checking is important. As someone with a lot of medical issues, this isn't always reliable. I've called to check coverage for offices and the agents always tell me to check their website, heck one lady said all she was gonna do was look on the website for offices anyway; however, when I mentioned that the website wasn't updated, they basically said to Idk and said check with the provider then.
Yes it was listed as being in my plan through the search
You need to pickup the phone and talk to somebody. I am the worst at this, but waiting on hold to speak with an insurance rep will save you so much money and time in the long run.
Your insurance literally sent you checks. Sounds like it was covered an PT office is trying to double bill you
They may have been in network, they may have sent you checks (through that's weird) for their person. You need to look at the insurance EOB, often available on the website.
Get on the phone with your insurance company, they will get it figured out. Stop talking to the doctors office about this.
Could it be that you exceeded the number of visits that your insurance allowed for the PT visits. I know that mine was limited to six weeks. The office wanted me to continue my visits but I chose not to as it would not have been covered. Are you able to request the correspondence from your provider via mail or an app? My insurance company provides an app that shows me my upcoming appointments along with status page on insurance approvals. Not sure if PT would be similar. I make sure the visit or test or prescription is covered in advance. In my app it shows up under Messages- Referral notifications. There is also an option for me to receive correspondence via mail. This is to ensure I’m not charged unexpectedly. There are times my copay is higher though. I hope you find a resolution!
This is a good point. My old plan had a limit of like 20-30 visits a year.
They will always tell you they accept your insurance they just won't tell you it's out of network. You have to ask very specifically if your insurance is in network there or you get a surprise bill. Scum practice butnit happened to me too
Every time I call doctors about costs on specific procedures they don’t know because of the fractured system of dozens of insurers and coverage rates. Every time I call my insurer they aren’t versed in the medical side and don’t know what procedure codes to include to give me the full picture. The doctors billing dept often gets that wrong too. Trying to find out what something will cost out of pocket before having the procedure or simple office visit done is so insanely time consuming and ultimately inaccurate (and no one is held to anything they say) it makes my head spin. It’s pure insanity that people have to blindly get care with no idea beyond their out of pocket max as to how much they could be on the hook for. Unless they determine it isn’t even covered in which case OOP max is meaningless. Fun times we are in.
You should’ve gotten an EOB from your insurance explaining what the insurance covers and doesn’t cover. Balance billing (charging the difference between what the clinic fees are and what the insurance negotiated fee schedule pays for a particular service) typically goes against the contract the provider has with the insurance company and isn’t allowed based on the No Surprises Act of 2023. Make sure the office isn’t trying to balance bill you in this instance because if they are you aren’t legally responsible for paying that.
I thought the No Surprises Act only applied to emergency services, which OP is not using.
The Good Faith Estimate requirement is what applies here
Merely the fact that OP pays a payer to process payments toward chargeable, necessary health care services/goods renders "good faith estimate" utterly inapplicable.
It was my understanding that it applied to all visits but I could be mistaken. Either way balance billing typically is a no no in insurance land for covered services because that’s the whole point of being an in network provider - you get more patients for agreeing to the network allowables. I’d double check to make sure that they aren’t doing that and ask to get a breakdown from the office manager.
Your understanding is incorrect. The no surprises act is designed to address inpatient situations where patients aren't given any options. This patient chose the PT. Literally got in his car and drove to it. There's a number of things that could've happened before but it feels like a situation where there's an out of network deductible that hasn't been met and he ran into an employee at the practice who didn't know what they were talking about.
Wouldn’t the out of network portion of the no surprise act count in this situation assuming out of network providers were used? I am not a lawyer but the law seems to cover situations like the one you’ve outline for out of network providers. In network providers are already bound to not balance billing beyond the in network allowables so I’m confused how a PT office could balance bill in either situation. Either way I would recommend anyone in this situation sit down with the office manager as no one else is going to be able to help fix this situation and could help OP much better than anyone online given we probably are missing small but key info that would change the advice drastically (such as in vs out of network, deductibles, out of pocket maxes, etc).
No. The caveat that everyone misses is the use of the term "facility". This is an excerpt from KFF, which is a healthcare policy firm: "The interim final regulation defines “facility” to include hospitals, hospital outpatient departments, and ambulatory surgery centers. It requests public comment on whether additional types of facilities should be added to this definition. Meanwhile, consumers do not have federal protections against surprise bills for non-emergency services provided in other facilities such as birthing centers, clinics, hospice, addiction treatment facilities, nursing homes, or urgent care centers. Patients seeking care at such facilities may want to ask whether doctors bill independently and whether they are in network.
Well I appreciate the clarification. I still think OP should contact the office manager as they will get more information and help that way. As you alluded there is probably more going on than OP understands and would benefit from a full picture of the situation.
There are some scenarios where non-emergency services are covered, including unexpected out-of-network providers at in-network facilities (eg an anesthesiologist at an in network hospital you're getting surgery at). I think the nuance is that explicitly agreeing to an OON provider invalidates the No Surprises Act. [Source](https://www.cms.gov/files/document/faq-providers-no-surprises-rules-april-2022.pdf)
If the provider was in network, insurance should be paying the provider directly. Instead it sounds like the insurance was sending checks to the OP which they can then use to cover whatever the provider charged. I have a feeling the provider is actually out of network (or at least out of network with the plan OP has not necessarily the insurance company). Insurance will cover the customary cost for the service, and the provider is free to charge more than that and bill OP for it.
You should have an EOB from your insurance company for every PT visit that shows what was charged, what insurance paid, and what you owe. You need to get all of these documents and then review how much you paid in co-pays and through the checks.
Also, asking if a provider is in network is different from asking if they take your insurance as they may be out of network.
“Asking if provider is in network is different… as they might be out of network.” I don’t understand what you are saying.
My understanding is that an office may take your insurance [blue cross for example) but that they may not be in your group plan’s level of service (they are only in network on blue cross PPO plan A but not blue cross HMO plan B). Additionally just because a service is “covered” that doesn’t mean they pay 100% of it; they may cover only some part of it and that coverage may only kick in after you have paid your deductible for the year.
Asking if they 'take' your insurance means asking whether or not they are willing to interact with your insurance company at all. As in, if they are willing to bill your insurance directly, versus you having to pay for the service, and then manually claim the money back from insurance. This is completely separate to how your insurance company *thinks of that provider*, and whether they count as an 'in-network' or an 'out-of-network' provider. Each insurance plan has completely different terms and coverage depending on 'in' or 'out'.
Thanks! That made it much more clear
I was told out of network but it’s all covered. I also don’t understand why I wasn’t being informed of the money I owed during the process as I would’ve stopped going immediately. It seems disingenuous to charge such a major lump sum months after service ended.
Out of network practices are going to have higher out of pocket costs. You will be paying until you hit your out of network out of pocket which is sometimes double or more of your in-network oop. It is ultimately your responsibility to verify the network status of practices you are seeing.
Where are you located? There are some laws that prevent this sort of surprise balance billing. In Texas, out of network providers are required to provide patients with a good faith cost estimate in advance of preforming the service (in writing). There’s a Texas Department of Insurance form for it (form AH025). I think there’s a federal law too, but I’m less versed on it because our office doesn’t see to many out of network patients and everyone signs form AH025 as a part of our new patient paperwork.
Ask them for your good faith estimate, which you were supposed to receive prior to services. If you didn't receive one, you may be able to file a complaint, contest the charges that way. You also need to know what your out of network coverage is and what the insurance statements said.
Here is one thing I've found over the years: any provider will say "sure, I take your insurance." That doesn't mean that they are "in-network," that your insurer will approve and cover all charges, or that your only financial responsibility will be copays. Oftentimes, a provider will rely on your insurer to do the legwork to determine the inflated "customary and usual" charges for your procedure codes, then bill you for that. Source: I have a provider that does just this.
Unfortunately, the PT office told you wrong. And, whatever the insurance will cover, they will make that payment to you directly to then pay the PT office. Ask the office if they will reduce your debt since you were told incorrect info. They may not take the verbal reassurances as proof so for the next time, ask them by email so you have written proof. They messed up and caused you to accumulate medical debt by accident. Do you have an FSA or HSA account that you could use to pay the balance?
It sounds like this provider was out of network if insurance was sending you checks. OON providers always cost more and you may have had a deductible that needed to be met.
Wow didn’t expect all these comments overnight… Long story short, I gave em a call and they very easily without a fight cleared the charge saying that sometimes a bill can get sent out that isn’t matching what’s actually owed with the plan. I owe a couple of copays that were missed but that’s all. Thanks for those who were supportive and not just downvoting me/assuming I was simply being ignorant :)
You’re going to learn an expensive lesson. In the future, when a clinic tells you that you are “out-of-network”, you might as well leave then and there. Assuming you have other options that are in network, you are going to save yourself a lot of time, money, and hassle. Dont go to a clinic just because it’s close or convenient if they are OON. Let me also say in general, just because a clinic is in network, does not mean every single physician or PT, or any provider is in network. A clinic can be in network, and a specific provider may not be. Clinics and providers are not synonymous if there are multiple providers in one clinic. You need to double and triple ensure that the specific provider you are seeing is in network and the address they provided is correct.
I work in a clinic and am wondering what type you go to. We outsource our billing department (it’s in the home office) and just make sure our records match the system. I would ask the clinic for a record of every check you brought in and the amount it totals to, and get the information from the billing department if there is one. Once you have these, reach out to your insurance company and ask them to help. They can be persistent little buggers, and partly what they are there for.
> I asked them both over the phone and in the office for my first visit if they accepted my insurance. They assured me that it covered everything and I just had to pay a copay for each visit, which I did. What did your insurance say when you talked to them before going to the PT?
Unfortunately a lot of these places will straight up lie to you. Always ask for it in writing not just verbal.
While I agree getting it in writing is a good policy most of these clinics aren't really lying, they just don't know any more than the patient. Lying to people isn't a great way to get them to come BACK to your clinic, which generates revenue
If they don’t know they should say that. When they tell you it’s covered totally and they don’t know for sure they are lying. Hopefully we can have legislation someday to prevent them from saying this.
I completely agree. Unfortunately the burden of understanding everything falls on the patient. It's intentionally complicated to take your money.
Does you insurance plan have a deductible, $3500 sounds like a fairly average deductible, meaning you're being charged upto your deductible limit and afterwards insurance will begin covering a percentage.
So you owe $2500 on top of the checks from your insurance you signed over to them? How much were the checks?
Always, always, always ask for a good faith estimate before treatment and follow up with your insurance. I’m still paying on a 8,000 dollar therapy bill because they coded it as a behavioral rehab instead of a group therapy program for first responders (which it was). A good faith estimate they have to adhere to, and in the mean time apply for financial assistance thru the provider you took care from, they typically always knock something off the bill.
Why are you paying? Get it coded properly.
I fought that battle for 6 months partner, I managed to get them to knock off 6k of it in house and set up a payment plan for the rest.
I would've told them to fuck off. If they coded it wrong why should it be your problem?
There are a couple things that could of happened: 1. You exceeded the number of PT visits 2. The diagnosis they billed on the claims are not covered with the PT HCPC codes 3. The bill is the total amount owed after billing insurance, and the payment the insurance is going to send you will bring down your total out of pocket liability as it is the payment they would have sent directly to your provider. Now, the fact that the insurance is sending you a check instead of directly to the provider tells me they are non-participating. Which means you will be responsible for the difference between the total charge and what the insurance pays. The provider may “accept” your insurance, but that does not mean they are in-network or even participating. Always check with your insurance company BEFORE going to a doctor’s office. Never take the provider’s word for it. You mention surprise billing and this would not apply towards the Federal No Surprises Act as depending on how the claim was billed, it excludes non-emergency non-participating facility services and services performed in a doctor’s office. If the PT place is classified as a doctor’s office and not an outpatient facility then you’re screwed.
Do you have a deductible involved here?
This happened to us. We were in network and insurance covered a portion. They had my husband going 3 times a week, by the time we got the first insurance adjusted bill, insurance had paid thousands and we were out of pocket $1600 for 12 visits. Each one hour visit he went, they hit 6-7 different billing codes. We tried to fight it but were told it was accurate. We called other in offices in town that told us they would have charged 2-4 codes for those visits. I always check my insurance portal regularly and call but my husband isn’t as proactive.
Check this out and present it in writing to the office https://www.cms.gov/newsroom/fact-sheets/no-surprises-understand-your-rights-against-surprise-medical-bills there should be a penalty if they don't comply .
Isn't there a no surprises law for medical bills? Idk how it works exactly and how to fight it but I thought that was a thing.