Insurance Question

wheeler · Dec 21, 2016 at 02:45 PM

Has anyone ever changed insurances while going to therapy? If so did your T adjust what they charged you or did the cost per session that you were charged stay the same?
When I first started with current T I was under insurance, that my T took but I still had to pay the difference. I now have new insurance that I pay a copay per session . However that copay is less than the difference between what t charges and what insurance pays her. My T says I have to pay that difference because we initially agreed upon that amount when I first started . I contend that I only pay the copay.

Pennster · Dec 21, 2016 at 03:06 PM

You should ring your insurance company and ask about what their contract with the doctor says. I believe you are right, but I understand that it's based on what that contract says. For the doctor to charge a different rate than what the insurance company decides could be insurance fraud- but there may be state-by-state variations so definitely check it out with them directly.

Dec 21, 2016 at 03:38 PM

It depends on their contract with your insurer and your policy. In network benefits may require that they cannot charge you more, which would be breach of contract w/the insurer or fraud possibly, but some out of network benefit stipulations explictly state you are required to make up the difference between what they charge and what insurance pays.

Best way is to look up your plan by googling or thru your account. Calling them is a good idea too, but they will often give you different answers to the same question. In my policy, it's clearly stated in the benefits book that I get online.

TishaBuv · Dec 21, 2016 at 03:46 PM

Quote:

Originally Posted by wheeler

Has anyone ever changed insurances while going to therapy? If so did your T adjust what they charged you or did the cost per session that you were charged stay the same?
When I first started with current T I was under insurance, that my T took but I still had to pay the difference. I now have new insurance that I pay a copay per session . However that copay is less than the difference between what t charges and what insurance pays her. My T says I have to pay that difference because we initially agreed upon that amount when I first started . I contend that I only pay the copay.

You therapist gets paid what they have contracted with each insurance provider regardless of what they charge. I find it quite unethical that your t said that. Call your insurance company to verify.

ruh roh · Dec 21, 2016 at 03:50 PM

There's co-pay and co-insurance. Co-pay is what your insurance company determines based on your plan. Could be $20, $30 or more. And then there is co-insurance which is the percentage of allowable charges not covered under your plan. For most of the best plans, co-insurance is 20% of what insurance allows for the rate.

So, what you owe (patient responsibility) depends on the amount of your co-pay, plus co-insurance under your plan. It sounds like your previous plan didn't have a co-pay, just the co-insurance, so that's why you could owe more now and your therapist may be right. Only your insurance company can tell you for sure. Also, the amount this insurance allows may be different as well.

atisketatasket · Dec 21, 2016 at 03:54 PM

And awesome title, rr!

Dec 21, 2016 at 03:54 PM

Quote:

Originally Posted by TishaBuv

You therapist gets paid what they have contracted with each insurance provider regardless of what they charge. I find it quite unethical that your t said that. Call your insurance company to verify.

I got the impression she is charging the same fee regardless of insurance and circumstances.

What they charge and what insurance pays are 2 different things. There is nothing unethical about that part of it. The insurance pays them the contracted amount regardless of what they charge. And if the new insurance pays less, and the policy requires the client to make up the difference, then the therapist is doing nothing wrong. Not very kind of her though!

Dec 21, 2016 at 04:07 PM

Much depends on whether the provider is in network or not, whether there is now a deductible to be met in addition to the copay, etc. It's a question to go over with the insurance company.

Lauliza · Dec 21, 2016 at 08:15 PM

Generally a T has a contracted amount that they are paid by the insurance company. What you owe depends on your insurance if you have a co pay. Some insurance companies pay less than others so she may not get her entire fee. My old T had a few of $135 per session. I paid $25, the insurance company paid her $40 and the rest was the "provider responsibility". I assumed this provider responsibility meant they just had to be taken as a loss, but apparently not. I don't think clients should have to worry about that stuff. It's probably not unethical but it wouldn't sit well with me either.

Dec 21, 2016 at 10:48 PM

Quote:

PPO plans

Here's an example of how in-network and out-of-network benefits compare in PPO plans.

In-network: You go to a doctor and the total charge is $250. You get a discount of $75 because you went to an in-network doctor and our negotiated rate with them is lower. We pay $140. You pay what’s left, which is $35.

Out-of-network: You go to a doctor and the total charge is $250. You won’t get a discount because the doctor is out-of-network. We still pay $140, but you’ll be responsible for what’s left, which is $110. We call this balance billing.

What i explained earlier. This is BCBS but similar to others as I was thinking about changing my benefits and noticed this is not uncommon. It could get really costly. Can you change your plan back?

Pennster · Dec 21, 2016 at 11:31 PM

Thanks for that, skies - I guess we just need to know whether it's in-network or out of it. Wheeler can clarify if this is in-network or out-of-network, but I think the op's use of the word copay implies it's in-network.

The in-network doctor doesn't usually get to do balance billing, as the insurance company has negotiated a different rate. (I don't want to overgeneralise as maybe it's different in different states? But it is my understanding that it can be a violation of the in-network doctor's contract with the insurance company to charge more (or less, for that matter) than the insurance company says the client is responsible for.

Dec 22, 2016 at 02:31 AM

I think i was reading it wrong. It does sound like shes trying to mske up for a lower reimbursement rate of the new insurance.

I hope wheeler comes back to tell us.

I dont know about you, but I'm dying of curiosity over here.

wheeler · Dec 22, 2016 at 07:38 AM

Thanks for all the feedback. My T is in network and she is 'balance billing'.
I talked to my T about it and she acknowledged that my copay is only $10.
To be honest it's not the extra money, it's just $4 extra a session , it's the paying for her care that sent me for a loop.

bfralex · Dec 28, 2016 at 10:40 PM

Quote:

Originally Posted by wheeler

Has anyone ever changed insurances while going to therapy? If so did your T adjust what they charged you or did the cost per session that you were charged stay the same?
When I first started with current T I was under insurance, that my T took but I still had to pay the difference. I now have new insurance that I pay a copay per session . However that copay is less than the difference between what t charges and what insurance pays her. My T says I have to pay that difference because we initially agreed upon that amount when I first started . I contend that I only pay the copay.

I had to...basically it's a pain in the butt. I basically had to finish paying what I owed to my old insurance (which was less than my new insurance), there was a change over month where my old insurance ended (no longer paying costs) and there was a grace period before my new insurance started. (basically I paid my old insurance at the beginning of the month, then the rest of the month I didn't pay, and the new insurance started upon the first payment the next month)

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atisketatasket Child of a lesser god Member Since Jun 2015 Location: Tartarus Posts: 19,143 (SuperPoster!) 8 12.4k hugs given	Dec 21, 2016 at 03:54 PM #6 And awesome title, rr!
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Anonymous50005 Guest Posts: n/a	Dec 21, 2016 at 04:07 PM #8 Much depends on whether the provider is in network or not, whether there is now a deductible to be met in addition to the copay, etc. It's a question to go over with the insurance company.
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Anonymous37926 Guest Posts: n/a	Dec 22, 2016 at 02:31 AM #12 I think i was reading it wrong. It does sound like shes trying to mske up for a lower reimbursement rate of the new insurance. I hope wheeler comes back to tell us. I dont know about you, but I'm dying of curiosity over here.
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wheeler Veteran Member Member Since Jan 2009 Posts: 541 15 102 hugs given	Dec 22, 2016 at 07:38 AM #13 Thanks for all the feedback. My T is in network and she is 'balance billing'. I talked to my T about it and she acknowledged that my copay is only $10. To be honest it's not the extra money, it's just $4 extra a session , it's the paying for her care that sent me for a loop. __________________ wheeler
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