posted
I have a questions for our Lyme Friends. Is it illegal or unethical for a Doctor to Not inform you that your insurance is not covering your appt. When they made it very clear that they did take your Insurance. I have been paying the co pay. I had seen her 3 x from November thru January and my kids saw her twice during this time. Never have I received a Bill until today. Yet it said I was 90 days & the kids were 60 days over due. I made a point at the first visit to ask the receptionist to make sure that our Insurance covered the visit. She told me that our Insurance did cover them. If her office had informed us that our Insurance wasn't covering our appt with her I would have never seen her after my first visit. Much less have taken my kids to her.
Posts: 188 | From NM | Registered: Feb 2006
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dmc
Frequent Contributor (1K+ posts)
Member # 5102
posted
Have you called the office about the bill? They may not have correct information of your insurance to file the claim properly.
It may have just been filed it wrong.
It is rare for any LLMD to accept insurance. If yours does/did you are really blessed.
Hope it gets resolved in your favor.
Posts: 2675 | From ct, usa | Registered: Jan 2004
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posted
Make sure there is not some mistake, as dmc said. I don't know if it's illegal or not.
Definitely call and talk to them about it .. and ask why you weren't billed earlier if they were going to bill you.
-------------------- --Lymetutu-- Opinions, not medical advice! Posts: 96239 | From Texas | Registered: Feb 2001
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Keebler
Honored Contributor (25K+ posts)
Member # 12673
posted
- I assume all claims have been filed by your doctor's office in a timely manner - and correctly.
If not, well, then that would be where to start again. If all that has been in order:
Ultimately, I do not interpret the problem source with the doctor's office - but with your insurance company and, most specifically with your plan, your coverage.
The doctor's office does have an arrangement with your company - yes. Still, that is not at all the same as your insurance company covering all, or ANY of the charges from that doctor for YOU.
The buck stops at the insurance company & what they will or will not cover - not in general but FOR YOU. Sadly, both doctors and patients get caught.
However, if your doctor has ordered tests or services that they know will not be covered by your insurance, that's another point.
But that is also hard to know in advance. Some insurance companies will not tell you in advance what is covered. Or we may have a list but there is some loophole due to a slight discrepancy with a diagnostic code.
Can you call your state's insurance commissioner or ombudsperson? What do others at the area lyme support groups report about your insurance coverage? -
Posts: 48021 | From Tree House | Registered: Jul 2007
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Keebler
Honored Contributor (25K+ posts)
Member # 12673
posted
- I assume you've already talked with your insurance company but I'd try again - this time going as close to the top as possible. Getting the person's name and then staying in contact with that same person for each call, if possible (and if they are doing a good job).
Realize, though, it is often their chosen path to try to deny services. Be careful in how much you disclose.
-----------------------------------------
New Mexico Department of Insurance State Insurance Commissioners Office
The New Mexico Insurance Division -
Posts: 48021 | From Tree House | Registered: Jul 2007
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Keebler
Honored Contributor (25K+ posts)
Member # 12673
posted
- Your insurance company will have a record of when claims have been filed.
However, for years now, my company (Medicare) has been doing a deceptive dance.
My doctor's office will submit the claim, but then Medicare rejects it about THREE times, each time because of some very minor matter.
Sometimes, then a date becomes too late and I'm stuck.
I have no real lyme coverage anyway but I've just stopped going to any doctor for any reason because no doctor is getting paid. It's embarrassing for me, not fair for them and the insurance company wins.
But I can't really even talk to them by phone because my ears are so tender and their phone system just too sharp on my ears. I also can't talk to any state agency. The risk of sound seizures outweighs everything in my case.
But, mostly, it's all the lies. There is no reason for Medicare to have rejected the filed claims for payment. I know that they got the claims and they will just say they did not.
I assume you have a different company but they all play these games.
Still, I hope I've not discouraged you (though I know I have) . . . but if you know some of the games they play, then you can be empowered to just not put up with it.
So, you might need to go back and forth between your doctor's billing clerk to see the date of when they submitted and
the date when your insurance company SAYS they received it.
It should not be so hard, I know. And I do hope you find the right persons who can open the door for you.
Good luck. -
Posts: 48021 | From Tree House | Registered: Jul 2007
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Tincup
Honored Contributor (10K+ posts)
Member # 5829
posted
Keebler,
You are amazing.
And good luck Gypsy! Don't let it go, fight the good fight.
posted
It turns out that The Doc office does take my Insurance but is not an In Network provider. This is where they went wrong.
When I first called to make my apt. When I first went to them they claimed to both take my Insurance and that they were an In Network provider.
I specifically asked these questions of the receptionist because I knew that if they were not covered or In Network we could not in no way afford to go to them. I told her this also. She said it was fine that they were & they never had an isue with my Insurance company not paying.
I spoke with my Insurance company, & they helped me figure out what had gone wrong. They also told me since I was out of Network the Docs office should have never asked for the co pay. That was another big No No on their part.
I called the Doc's office on Monday & spoke to the receptionist. They claimed they would call me back in the morning as usual nothing no call back. I called again I spoke to the same receptionist again claimed she needed to talk to the Doc and she would call me back in 30 min. Again no call back. It is Friday.
I spoke with a Consumer Fraud Lawyer, & they said I definitely have a case. As they violated the Consumer UPA (Unfair Practice Act). By stating they were an in network provider when they were not.
This Doc is trying to make a name for herself in the Lyme Community. But as far as what I have seen she has some shady business dealing and is not at all what she appears to be in the Lyme Treatment dept. I would not recommend her to anyone. I have spoken to another ex patient that feels the same way.
Posts: 188 | From NM | Registered: Feb 2006
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-------------------- --Lymetutu-- Opinions, not medical advice! Posts: 96239 | From Texas | Registered: Feb 2001
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desertwind
Frequent Contributor (1K+ posts)
Member # 25256
posted
That is quite confusing the manner in which you were told they "take" your insurance. I can understand your frustration!
What do they mean by "take"....
I am a Licensed Mental Health provider (Ph.D. Clinical Psych.) and I would only claim to "take" someones insurance if indeed I was a provider/had a contract with their insurance company.
If I was not a provider and the patient has out of network benefits then they are told up front that they are responsible for the payment at the time of service.
The patient would need to submit into their insurance a Superbill/HICFA that I provide with billable codes/diagnosis.
Some doctors will submitt for you if you are out of netowork and take assignment of your benefits. Maybe that is what you LLMD meant?
So, I think alot of pracitioners are misleading when they say they "take" your insurance when they are not in network. There should be a much clearer understanding of what that means.
Posts: 1671 | From Tick Infested New Jersey | Registered: Apr 2010
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posted
The thing is desertwind. Is they took my co pay which is only what an In Network provider should do. Since they did not have a contract with my Insurance provider they were not allowed to even ask for it. Which the front desk wombmyn did. They took the co pay for all 3 of my appointments and for the two appointments for both my kids.
Posts: 188 | From NM | Registered: Feb 2006
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posted
Hubby and I have learned the hard way also -- if it is going to be an expensive appointment with a new doc then we call our insurance company before the appointment to make sure we understand if the doc is in or out of network.
Yes, it is a hassle, but it makes things go much more smoothly to know upfront exactly what a new patient appointment will cost.
I agree that the practice sounds unethical -- hubby had a doc charge him $400 once to do a celiac disease test. It was an in network provider and they should have accepted the few dollars insurance was willing to pay.
At the time we knew the doc was bending the rules and they admitted to us that they were. So we did have a choice whether or not to have the test done. He was very sick at the time and we didn't want to have to find another doc who would order the test so we did pay.
Another time a doc who was out of network scared hubby into having an expensive echo cardiogram done. We could have waited and had it done by an in network doc, but the doc made it sound like it was more urgent than it really was.
Sorry you are in such a mess. I would probably pursue legal resolution of this issue myself. If you do decide to pursue it then you need to ask the lawyer if you should just refuse to pay the bill or if you should pay and then request a refund. It is possible that a letter from a lawyer could resolve the issue without resulting in an actual court case. I would probably try that first.
Bea Seibert
Posts: 7306 | From Martinsville,VA,USA | Registered: Oct 2004
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posted
Thank you Bea, I am sorry you have gone through similar situations. I am going to pursue legal resolution. Thanks for the encouragement.
Posts: 188 | From NM | Registered: Feb 2006
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desertwind
Frequent Contributor (1K+ posts)
Member # 25256
posted
Lymegypsy; Seems like the front dest totally screwed up! By taking your co-pay they are acting like an in-network provider.
It is all wrong - what they did - they should be working with you to rectify the situation.
Posts: 1671 | From Tick Infested New Jersey | Registered: Apr 2010
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