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 Posted: Sat Nov 28, 2009 1:21 pm Post subject: Insurance Out Of Network Fee Reduced to patient...Legal? |
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| My insurance pays 50% of my mental health therapy sessions(im in nyc).....my doctor has agreed to bill his standard rate to the insurance company ie $150 per hour ...the insurance would pay $75 to my doctor and since i cant really afford to pay $75(ie remaining 50%) my doctor has agreed to take $35 from me instead.......my doctor is a kind caring individual.....and i dont want this act of altruism to get anyone in trouble....is this legal, etc? |
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east30s
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| Posted: Sat Nov 28, 2009 1:39 pm Post subject: |
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| Absolutely. Your policy only states that it will pay 50%, but if your doctor agrees to charge less, thats between you and him. |
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Trench
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| Posted: Sat Nov 28, 2009 1:42 pm Post subject: |
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| thanks.....so the insurance company doesnt care that in reality my doctor is really only recoupin $75 plus $35 = $110 vs the $150 which is his standard rate....ie he doesnt have to charge $110 to insurance company instead....where they pay $55 and i pay $55? |
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east30s
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| Posted: Sat Nov 28, 2009 1:45 pm Post subject: |
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| Like I said, if he agrees to charge you less, thats his decsion. Besides, the money the insurance company pays does not belong to them, it's your money. Similiar situation, my pediatrian is a family friend and doesn't charge us for doctors visits that my carrier reiumburses me for. |
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Trench
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| Posted: Sat Nov 28, 2009 1:55 pm Post subject: |
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| ok thanks.....just wanted to make sure that from a legal perspective it wasnt against the law.....sounds like its not.....can i ask...are you an insurance expert? |
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east30s
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| Posted: Sat Nov 28, 2009 1:57 pm Post subject: |
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| No I am not an expert. |
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Trench
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| Posted: Sun Nov 29, 2009 5:16 am Post subject: |
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| Quote: | | No I am not an expert |
But he is correct. 
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Dasfuk
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| Posted: Sun Nov 29, 2009 5:47 am Post subject: |
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By law this is classified as insurance fraud.
"Routine waiver of a patient's copayment or deductible."
I had to defend myself early in my profession because of this. |
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donti32
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| Posted: Sun Nov 29, 2009 1:45 pm Post subject: |
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| Quote: | By law this is classified as insurance fraud.
"Routine waiver of a patient's copayment or deductible." |
This is not what we are talking about. |
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Trench
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| Posted: Sun Nov 29, 2009 5:26 pm Post subject: |
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| not sure i follow....are you saying if the doctor WAIVES copayment or coinsurance it is considered insurance fraud but if he charges you a lesser copayment/coinsurance, its ok? |
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east30s
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| Posted: Sun Nov 29, 2009 6:17 pm Post subject: |
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| Lowering one's price in order to save a customer's deductible is not illegal. It is not illegal to waive a deductible as long as the insurance company is not being overcharged for anything the policy covers. However, you maybe recieving substandard services. |
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Trench
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| Posted: Sun Nov 29, 2009 10:57 pm Post subject: |
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| Trench....its not my deductible that would be lowered...its the copayment......Just wanted to ensure that the information you are providing is from a legal source OR is it hearsay? thanks for the response |
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east30s
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| Posted: Sun Nov 29, 2009 11:55 pm Post subject: |
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| Deductible/copay same difference. You are still paying your copay, only your doctor has lowered it. As long as he is not over charging your carrier to cover the difference and he is taking the loss, no harm no foul. If he is false billing your carrier to make up for the difference, that would be illegal. |
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Trench
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| Posted: Mon Nov 30, 2009 4:47 pm Post subject: |
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Sorry, east30s, as an insurance expert, your coinsurance is NOT being lowered. You are the beneficiary of what's known as "balance billing." Coinsurance is purely what the insurance company contracts to pay. 50%, 60%, 70%, it doesn't matter -- you pay the "balance" after the insurer has met its responsibility.
If you're in an HMO or PPO, and use a network provider, the most you'll be responsible for is your portion of the 100% (30%, 40%, 50%) of the allowable charge the insurance company does not pay. Out of network, the rules are entirely different. Your provider may bill $150, and if the insurer pays $75, then the total amount is within their definition of "usual, customary, or reasonable." That your provider is willing to "waive" some of your remaining balance is his/her personal choice.
It has absolutely nothing to do with your coinsurance. It is not fraud, it is not a crime.
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MaxHerr
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| Posted: Mon Nov 30, 2009 6:36 pm Post subject: |
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| Quote: | | your coinsurance is NOT being lowered. |
How is it not? His doctor presumably is not collecting the remaining 50% of the coinsurance and not presumably burying the difference and charging the carrier to make up for it, instead is taking the loss. |
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Trench
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