HealthCareProvider Refuses Refund of Overpayment

[DCpersoninNY]

What is the name of your state? Washington DC AND New York

I am an insured person with a health care policy out of Washington DC, that is usable anywhere I work or travel. That means I can use an IN NETWORK provider located anywhere in America, or the world.

I was on assignment in New York City and used a health care provider regularly for therapeutic services. The Health Care Provider was IN NETWORK. I decided to pay in full what the health care provider asked for each visit and then sent in my 2006 and then 2007 PAID IN FULL Statements of Services to my health insurance company. The health care provider Knew I was using them as an insured in-network person with this insurance

The health insurance company found that I had been overcharged by $40 a visit according to their fee per visit for this type of health therapy, and that therefore the Provider needed to refund me the $40 I overpaid for each and every visit. The Health Care provider jerked me and the insurance company around for 6 months, in which I supplied cancelled checks etc. THEY EVEN ACCEPTED A PAYMENT FOR SERVICE DATES THEY HAD BEEN PAID BY ME, FROM THE INSURANCE COMPANY.

I have never beenm reimbursed, and despite phone calls and letters from me and the insurance company, they still have stiffed me. The insurance company has totally wimped out leaving me hold the bag. They have washed their hands, and not even dumped this service provider from their network.

What do I do? If your answer is take them to small claims court, do I do it in NY or DC?

I'd like to hear from a lawyer or someone who can address the 2 state aspect as well.

Thanks Carol (its a BCBS involved)

[justalayman]

Sorry to hear you had problems with BCBS. I have had nothing but great experineces with them.

So, hopefully the first lesson you have learned is do not pay the provider anything. Unless you have an odd plan, BCBS contracts with the providers that a bill will not even be issued to the patient until a EOB is generated. You should pay only any co-pay required and wait for a billing after that.

As to where to sue; it is awlways easier to sue in their home court. If you try to sue in another jurisdiction, they can contest on those grounds. If you would end up winning in your home court, you still could not have the judgement enforced without domesticating it into their home court anyway. A lot of work to consider fighting it in your local courts with an even more difficult chance of collecting.

[DCpersoninNY]

Thanks..your info about where NOT to file was very helpful.

My problem with BCBS was that they refused to discipline an in network provider who violated their contract with BCBS to accept the fee set by BCBS. They double charged me, a paying member and when the Service Provider refused to do the right thing and refund the overage I paid, BCBS, slinked away.

The service provider was guilty of fraud, and BCBS didnt do a thing leaving this service provider in business, under the BCBS name, to stiff someone else.

Carol

[Insurance Pro]

When discussing in-network/out-of-network plans, you must remember that the negotiated fee that an in-network provider receives is between the health plan and the provider of services. It is NOT between the patient and the doctor. It appears as if your provider simply considered you a "fee-for-service" patient, and that generally means that the provider can charge whatever he wants. Insurance will pay what insurance will pay based on the contract. The insurer will normally consider what is referred to as the "UCR" (usual, customary and reasonable) charges for a given geographical area and base their reimbursement to the patient as a percentage of the UCR charge. If, as another poster stated, you had simply let the provider bill the insurer, the negotiated rate would have been honored. Unfortunately, your proactive approach to "get the bills out of the way" seems to have cost you. I believe that you have no real legal recourse against the insurer, and you may (stress may) have recourse against the provider. Frankly, that's doubtful. The doctor should, as a matter of conscience, refund the difference.

[moburkes]

Sue them for what you think they owe you.