Seeking advice on copay dispute

I hate this for you, man.

If there IS a co-pay, what’s the amount?

If you give us Ginny’s number, I’m happy to go all Patti Lupone on her.

But you’re probably gonna have to pay it.

You'll need copies of your Explanation of Benefits (EOB), which shows what the therapist is paid, and your responsibility.

At some point soon, because there are statutes of limitations for this stuff, you need to get, preferably in writing, an explanation from the practice's billing people, outlining exactly why they believe you, with your insurance plan and any other relevant circumstances, owe them a copay. Their response would need to be more than "because I say so." It should have to do with the particular insurance type, services rendered, and what the contract between insurer and therapy practice says are the correct reimbursements.

Most therapists use third-party billing services. Most of this billing work is automated, computerized. The biller may not even know what the actual terms are. They are probably entering some codes into a computer program and sending it to the insurance company. It's possible an error is occurring at that level. The billers may be using the wrong codes, either for service type or your insurance plan. It happens, but won't be discovered until somebody is willing or forced to take a close look at the details.

Insurance has the legal power to tell your shrink's office to pound sand if they are not abiding by their insurance contract. They can also retract payments from the provider's office if they determine they or you have overpaid.

This has only happened a few times in my life. One time it was a dentist's office that was engaging in wholly shady practices, and the insurer terminated their contract for what they said appeared to be billing fraud. The other time the surgical center tried to up-bill me for unbundled anesthesia services that were already covered under the original payment. What I learned from these experiences is that you must save every document, document every phone call, and be very patient for things to move slowly towards a resolution.

I don't know if you have public or private insurance or what state you're in. But many jurisdictions say if a mistake is made about in- vs. out-of-network or other coverages, if the patient acted in good faith and/or received bad information, the patient is not obligated to pay under any circumstances.

You have a state department of insurance that is a last resort if you can't get cooperation or resolution about this. You will also need to waste time talking to your therapist about how they feel this should be handled, and what they are willing to do, and how patient they are willing to be awaiting a resolution.

But the very first thing for you to do now is to send a letter with proof of service to the therapist's office and your insurance, explaining that you don't owe this copay, and asking for their assistance in resolving the billing snafu.

Bail because obviously the billing person doesn't have her shit together and you can't afford it. You are probably not going to win this battle, unfortunately.

If the therapist has contracted with your insurer to accept a certain fee and your insurance is paying the agreed fee, how can the therapist look to you for additional payments?

Thanks for the helpful replies.

A friend has just told me there’s some state board that provides oversight in health plan disputes …but she warned that it’s a heavily bureaucratic process I may not want to deal with. I’m inclined to agree. Sometimes being right isn’t enough.

But what about posting the details in a Google and/or Yelp review of the clinic? A good idea?

They can't and remain in compliance with the contract they signed.

Why isn't the therapist talking to "Ginny" the billing person and telling her what the insuror has told them, you, and her and asking why she continues to bill you?

It's up to the therapist - do they value you, and their contract with the insurance company, more that their billing person who, if wrong here, is likely wrong elsewhere.

Yes, OP R5, submit that Yelp review. Go ahead and nuke any possible goodwill with the clinic, any possible ongoing constructive relationship with the shrink, because you have not responded in the legally required manner to a billing problem. They have created this problem it's true. But you have specific legally outlined responsibilities and timelines to deal with these things. Your inaction will allow them to prevail.

It's a scam and the therapist knows it perfectly well and is part of the setup. You're supposed to just pay the extra without making a fuss, op.

Ginny from Billing is a bitch!

It depends on how much the copay is and if it's a therapist you like.

If it's like $25 or something you can afford - proceed while you verify what the situation is.

If you only need to go a couple of sessions, go - pay it - the write a truthful 2-star review that the therapist was great but that Ginny was terrible to deal with and you would advise people not to go for that reason.

Ginny will shit her pants.

I thought Ginny from Billing was dead? ANYWAY, we went through something similar. My husband needed new hearing aids. The closest in-network was 100 miles away, so BCBS-Anthem agreed to bring his supplier into the network. All signed, sealed, and delivered. He got his new hearing aids and a bill for $1200 a couple of weeks later. Their Ginny in Billing said that it didn't matter what the insurance contract said, he had to pay it as the amount was more than the contracted insurance amount. A call from BCBS-Anthem set them straight.

I suggest you get your insurer on them. Pronto.

Someone as evil as Ginny never really dies, R11.

I get this constantly from my dentist’s office. The billing person is insistent on a certain amount. I check with my insurance and then have to convince the billing person.

You owe what the EOB says and that’s it. BUT, Ive also had to dealt with my insurance when the EOB is wrong, always in the favor of the insurance company.

We need single payer healthcare so badly in the US!!

It's a SCAM to get more money out of you. Leave this therapist. He is not helpful.

R13 - Yeah - I hate to say but I had that happen at a dentist office. I paid a certain amount and 3 months later they said the original estimate and payment wasn't right and there was an extra $1200. I paid it just to be done with it and I had a lot of other things going on at that time.

But in hindsight, I should not have paid it. It was her job to provide an accurate estimate based on my insurance. She didn't seem embarassed or apologetic at all.

I HATE dentist offices in the past 10-15 years. Always trying to upsell and I honestly have ZERO confidence in what they are saying is true anymore. It's not medical - it's a constant upgrade and get as much money as they can out of you.

Medical billing is one of these “partially automated” processes. Unfortunately even a great physician or therapist or dentist can struggle to staff their office, and the quality of office support is often really poor. I dropped a physician who was highly recommended by my doctor because the office manager was basically impossible to deal with. When I asked for another referral, my doctor looked at me and said “it’s Rhonda, isn’t it?”.

When I say “partially automated”, I mean you might receive all kinds of faux-helpful reminders and updates, and robocalls. I got so many intrusive robocalls from one physician’s office that I had to block the number. Why? Because they changed their software without fully migrating my data out of the first system.

You can expect to fill out the same information on an online portal, then again filling it in or reviewing that information at the office when you arrive, or (as bad) be handed a tablet in a plastic frame for you to type in all your data and pharmacy, emergency contacts, etc. On one recent visit to my dermatologist, the office clerk had to reset the tablet five times before I was able to access my forms. It’s really irritating and must be so hard for older people.

A lot of medical office receptionists focus pretty hard on avoiding eye contact, being really brusque and dismissive. I see some patients so confused and upset that they begin to cry. It’s all pretty awful.

Dental insurance is practically useless.

Seriously, r17. I haven't been in a few too many years, but a front-facing tooth of mine which has had 3 fillings (and lost them all) finally sent me. They said a filling on this tooth would never hold and that I needed a crown (my first ever).

Imagine my surprise when I find out that my crown is going to cost me (after insurance) $834 out of pocket. WTF do I even have dental insurance for? Anyway, I have the temp crown on and will be getting the perm within the next couple of weeks. OF COURSE I had to pay upfront for it.

Sounds like the therapist works for a group practice. Most therapists who have their own practices handle their own billing.

That the therapist in question had to appeal, it sounds like billing won’t budge. Whereas, if the practice is his, solo, he can “KIND OF” do what he wants.

A therapist’s rate is determined by the insurance company. The therapist is not allowed to charge more (or less, really).

HOWEVER, the client has his/her own contract with insurance. And, if there plan says they must pay a co-pay, they have to pay it.

The therapist would be in violation of their contract with an insurance company if they chose not to charge/expect the copay.