Medical Billing Forum

Billing => Billing => Topic started by: slcoop1234 on March 30, 2012, 04:48:19 PM

Title: doctor charging more than co-pay
Post by: slcoop1234 on March 30, 2012, 04:48:19 PM
I have been seeing a therapist (Ph.D.) for about 10 years. In January2011, my insurance was changed to a new company. This company has a contract with my therapist to pay him less than the old copmany paid him, but he agreed to that. The new co-pay also is less than the co-pay was under the old company. My therapist wants me to pay more than the required co-pay because he says that this company does not pay enough and he is worth more. He told me that he would no longer keep me as a patient if I did not agree to pay the extra money. He says that he has other patients who also have this company and who pay more than the required co-pay, more than he is asking of me.

Does anyone have any thoughts on this. It seems that I am stuck, doesn't it? I really have trouble affording the amount requested, which I told the therapist. He said I should cut back somewhere.
Title: Re: doctor charging more than co-pay
Post by: PMRNC on March 30, 2012, 05:33:38 PM
Ok, he cannot just TELL you he won't see you anymore, he has to follow procedures for patient termination and it's not that cut/dry that he can terminate a patient over something that hasn't happened yet (copay's leading to high balance).  Terminating a patient is not as easy as just telling them, in fact that's against the law. 

However..   He does have a right to expect you to pay the full balance of the difference SO LONG as he is non participating with your insurance carrier. IF he is participating, he is obligated to only collect up to the carriers allowable amount.  So if he's NON participating, you would owe him the difference between what was billed and what the carrier paid. In fact provider's are obligated to collect patient out-of-pocket's and you are obligated under your own policy to pay out of pocket expenses, this is the cost sharing provision of your plan's policy.
Title: Re: doctor charging more than co-pay
Post by: slcoop1234 on March 30, 2012, 06:21:12 PM
I guess that I was not clear. YES, he IS participating. That is why he gets a certain amount from the insurance company. They have a contract. Also, I KNOW that he cannot just get rid of me, that there are procedures that he must follow. However, I have been seeing this guy for over TEN YEARS. Do you really think that I want to change therapists?
Title: Re: doctor charging more than co-pay
Post by: PMRNC on March 31, 2012, 10:00:55 AM
If he is participating you only are obligated to pay him the copay (out of pocket) anything over the allowable he has to adjust off, according to his contract with that carrier. So if the new carriers "allowable" is less, that's not your problem.  If he is asking you to pay the difference between the old carriers allowable and the new carriers allowable that's completely against the contract he has with the carrier. I understand you don't want to change therapists, so I would approach him with this information gently and see what he says. If he still insists, well, you could go to your insurance carrier and they would take the matter up with him. 
Title: Re: doctor charging more than co-pay
Post by: slcoop1234 on March 31, 2012, 06:04:00 PM
Thanks for your answer. I have been paying him the extra since January of 2011. I am having  trouble affording it, so I did ask him about it (yes, gently). That is when he told me that he was worth more, and that other patients were paying him more, too. In fact, more than I am paying. He is unhappy with the amount the carrier pays. I told him that the stated copay is what I should pay and that is when he said he did not have to keep me as a patient. Of course, if I call the carrier, and they take it up with him, he will know it was me. Moreover, they will probably drop him. Then  I would not have any coverage to go to him at all. So I really am sunk, right?
Title: Re: doctor charging more than co-pay
Post by: Michele on April 01, 2012, 07:11:26 AM
If he feels that he is worth more then his issue should be with your insurance carrier not you.  He signed a contract with them agreeing to accept that amount AND agreeing NOT to charge you more than the copay.  If he is doing this with other patients and any one of you report him to your insurance carrier they will most likely drop him from their panel immediately.  This is definitely a breech of contract.  It would have been different if he had told you that he was considering resigning from your insurance carrier and that he may not be in network after XX date but he cannot request you pay him more because he is "worth more". 
Title: Re: doctor charging more than co-pay
Post by: PMRNC on April 01, 2012, 10:37:05 AM
I certainly would not want a therapist like that! I deal mostly with mental health professionals and I can tell you that you can find much better! Your not sunk unless you want to be sunk. What he is doing is not only unethical but it's against his contract with the insurance company and he's holding YOU hostage to it. JMHO, but he should not be able to do this, and I'm sure it's not only you he's doing it with.
Title: Re: doctor charging more than co-pay
Post by: slcoop1234 on April 01, 2012, 08:28:04 PM
Of course, I know you are right, but please consider that I have a long-standing relationship with this guy. If I do anything, particularly if my carrier drops him, I lose my therapist. My relationship with him is of quite a bit of value, don't you think? I know I can't do anything without damaging that, and may be even losing my coverage completely, but I just wish that there were some way the carrier could make him stop, without him knowing I had anything to do with it and without the carrier dropping him. It does make me resentful of him and mistrustful of him, which also damages the relationship, but I still need to talk to him. He is pretty sleazy in this way, I think.
Title: Re: doctor charging more than co-pay
Post by: PMRNC on April 02, 2012, 06:32:14 AM
You can speak with your carrier and explain the situation, I don't believe they necessarily tell them who made the complaint. 
Title: Re: doctor charging more than co-pay
Post by: slcoop1234 on April 02, 2012, 10:23:28 AM
He will know that I was the one who claled since I just brought this up with him last week, objecting to his demand.
Title: Re: doctor charging more than co-pay
Post by: PMRNC on April 02, 2012, 01:13:38 PM
Here's an idea.. why don't you play dumb.. :) Don't be insulted, I mean when you go for your next appt, and go to pay him, pay him the copay your plan says to pay, and then say this.. Oh, I did have a chance to check with my carrier and they said I can only pay the copay that is in my policy plan, I can't pay anymore as it's against my policy plan provisions. :)   It really would be a violation of your plan's policy contract, so let him connect the dots that he too is violating his contract by trying to collect more. He will :)    I really would hate to see you be blackmailed into staying with this provider, and that's exactly what you would be doing if you gave in and gave him the difference. You also set a precedent that he can get away with it and you are probably not the only one he's doing it to. 
Title: Re: doctor charging more than co-pay
Post by: slcoop1234 on April 03, 2012, 09:30:45 AM
I am going to try that; thanks for the idea. I know he is doing it to toher people with thisplan. He told me that he is and that those other people are paying even more than I am (by way of coersion). I'm also sure that he knows that he is breaking his contract. He's very smart but he doesn't care. But I am cgoing to try your idea and see if that persuades him or shames him. Thanks.
Title: Re: doctor charging more than co-pay
Post by: PMRNC on April 03, 2012, 11:00:16 AM
If he's doing it to others with the same plan, than he may not know it would be you to call them and let them know. Please remember that he's not only taking advantage of you, but others as well as the insurance carrier, in the long run, this contributes to abuse of the system overall and higher premium's.
Title: Re: doctor charging more than co-pay
Post by: rdmoore2003 on April 03, 2012, 11:30:18 AM
providers like this is one of the reasons healthcare costs have skyrocketed.  You alos have an obligation to your insurance company to give them this information.  I work in mental health also and unless you have a long term intense diagnosis, 10 years may be a bit much and maybe he is not the "therapist" for you.   If he thinks is worth more, than he can renegotiate his contract but you need to decide either way.
Title: Re: doctor charging more than co-pay
Post by: PMRNC on April 03, 2012, 12:01:48 PM
Quote
providers like this is one of the reasons healthcare costs have skyrocketed.  You alos have an obligation to your insurance company to give them this information.  I work in mental health also and unless you have a long term intense diagnosis, 10 years may be a bit much and maybe he is not the "therapist" for you.   If he thinks is worth more, than he can renegotiate his contract but you need to decide either way.

I agree completely. If this was one of our clients we'd even be LEGALLY obligated to report it.
Title: Re: doctor charging more than co-pay
Post by: Jmari3 on April 03, 2012, 01:41:13 PM
I agree with Regina, 10 years is a long time.   I know this is non of my business, but I feel compelled to say something on a personal note.... people get very attached to their therapists and forget that they have the power to be healthy within themselves.  You are functioning and healthy because of YOU, not him. As a therapist he understands his patients dependence on him and is using it to blackmail you all.  That's a touch evil.
Maybe seeing someone else is just the change you need, someone with fresh new ideas to help you.  I feel bad that you have to deal with this. 
I wish you all the best!  :)
Title: Re: doctor charging more than co-pay
Post by: slcoop1234 on April 07, 2012, 09:34:23 AM
Thank you for your kind comments. However, I may be functioning, but I am still in need of a therapist. And yes, you are right, I am attached to my therapist, as people do become. And yes, it is blackmail and it is a touch evil, but being a touch evil is also a human trait/failing. I have tor emember that my therapist is only human and susceptible to foibles. Although what he is doing is clearly wrong and harmful to me and to others in the system at large, I really unable to make a  change. Of course, if the carrier finds out what he is doing, they will drop him. Then I will have no coverage and no ability to continue therapy. So getting the carrier involved is not a solution for me.
Title: Re: doctor charging more than co-pay
Post by: Michele on April 08, 2012, 12:30:00 PM
You truly are in a tough spot.  Good luck with however you decide to handle it.