NA Insurance co/Dr. dilemma

Let'sgoflying!

Let'sgoflying!

Touchdown! Greaser!
Joined
Feb 23, 2005
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Location
west Texas
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Dave Taylor
What would you do?

I went for an elective diagnostic procedure.
I told them upfront I would be self paying as I am no where near, and would not meet my deductible.
I asked the self-pay price. About 1000$
During check in they insisted on insurance info. I repeated I am self-pay and asked them to not make an insurance claim, I would submit my bill to them to get credit towards my deductible.
I had the procedure and during checkout paid the entire self-pay amount. $1000 My bill says balance $0.00

I get notice from my insurer that the Dr office made a claim for ~$4000 which they paid in full.

I called my insurer to verify, yes they paid that amount.
I told them of my payment.

She said call the Dr. office back and ask for a refund. I said why? - you as my insurer should be pursuing your $4000 because it was an undeserved payment. I will have to pay my $1000 anyway as I am not near my deductible.

She said it would be difficult. It would be easier to let it go or me try to get my refund of $1000.

I said that as my insurer I would hope you would try to keep premiums down by pursuing fraudulent or erroneous claims vigorously. She was not interested but did give me contact info for the claims department.

What would you do?

Yes, the current system is messed up bad but don't send my thread into SZ with comments about how the new system will be worse, please. I am looking for solid suggestions on my dilemma.
 
Even when I'm nowhere near my deductible I still have them turn the claim into insurance as the insurance company always negotiates a better rate for me and cuts the cost in about half.

As to how to resolve your situation - no idea...
 
Why would you not want to go through your insurance company since that way the $1000 would count towards your deductible in the future? Or is your deductible not yearly?

A year or so ago I also had an elective screening procedure (the one you are supposed to get at age 50). I thought it was completely covered by insurance but when I got to the hospital they asked for the deductible which was less than the procedure. I paid it, but a month or so later I was surprised to find a refund check in the mail from the surgery center without me doing anything.
 
Jesse, the reverse is true here. If I self-pay, the amount I pay is a fraction of what it is if I don't self-pay. That is because of my high-deductible. If I run it through the insurance, the negotiated rate for the procedure is several multiples of their self-pay rate. Because I am not near my deductible....the insurance co pays 0 and I pay it all.

Mari, same thing applies. My 1000 does go towards my deductible.....I just have to submit my bills to the insurance co after I pay the bills.
 
Dave:

What they did is fraud.
 
I think I would feel compelled to be in their business office Monday morning with paid bill and insurance company payment notice in hand. With any luck at all, the person you first talk to will be named Houston.

Let'sgoflying! said:
Unless there is some info I am missing, that is what I thought.
Click to expand...
 
SCCutler said:
Dave:

What they did is fraud.
Click to expand...

Not necessarily Spike. I am sure Dave was very clear with the staff at the desk however when the doc turns back the file or chart with the procedure indicated it is very likely that the billing clerk or coding clerk coded it and sent it becuse the person that Dave spoke to never transmitted the info to the coding clerk or billing clerk.
 
I hope you can get this straightened out. So far, it doesn't add up.

I assume the doc is a participating provider with your insurance. If you indeed haven't met your deductible, the following sequence of events should have happened:

- you have the procedure, you pay your anticipated responsibility
- the docs office would have transmitted the $4000 charge to the insurance
- the insurance sends a remittance advice to the practice with code CO45 for $3000 (the amount the practice has to write off as contractual discount) and code PR1 for $1000 (the amount that is patient responsibility, in this case deductible) the insurance wouldn't have paid anything.
- the practice reconciles your payment at time of service with your eventual responsibility and either sends you a bill if you still owe or a refund if you overpaid.

If the practice has a participating provider agreement with your insurer they HAVE to submit a claim for every subscriber they treat. I doubt that the insurance paid the full amount billed, if they did, please let me know because I really want to get on THAT insurers roster. In all likelihood, your bills are still somewhere in the process described above and what whoever you talked to saw were raw charges (also known as 'funny money') and not an actual insurance payment.

Talk to the office or billing manager to sort this out.
 
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