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  1. #1
    CRAFTMASTERS is offline Junior Member
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    Angry Medical Provider Will Not Refund Overpayment

    What is the name of your state? ILLINOIS
    I use our local Doctors Family Pratice for medical care. They are a Health Link provider with my insurance company. We have to pay for services at the time of service then I file the claim myself with my insurance company.
    I always send a copy of the cancelled check along with the documents the Doctors office give me to the insurance company. We have a health link discount and on my explanation of benefits it says "you need to request a refund from the provider on the discounted amount. Be sure to make a copy of this EOB and send it in with your refund request"

    Doctors Family Pratice has not refunded any of my request and I am owed almost $2,000.00. I have called and called and no one will return my calls. This has gone on since 9/05 and it is 4/06! Who can I contact to help me? My insurance company said they can do nothing and I cannot afford an attorney. I can not even find a law on the books that tells me they have to honor my request.
    Which leads me to believe that if I pay for my services up front out of my pocket I do not get a discount, but if my insurance company pays it then I get the discount?

    I would be grateful for any direction or information
    Jo
  2. #2
    SingleMom67 is offline Member
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    To start, have you sent your request to the doctor's office via certified mail, return receipt?
  3. #3
    seniorjudge is offline Senior Member
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    Quote Originally Posted by CRAFTMASTERS
    What is the name of your state? ILLINOIS
    I use our local Doctors Family Pratice for medical care. They are a Health Link provider with my insurance company. We have to pay for services at the time of service then I file the claim myself with my insurance company.
    I always send a copy of the cancelled check along with the documents the Doctors office give me to the insurance company. We have a health link discount and on my explanation of benefits it says "you need to request a refund from the provider on the discounted amount. Be sure to make a copy of this EOB and send it in with your refund request"

    Doctors Family Pratice has not refunded any of my request and I am owed almost $2,000.00. I have called and called and no one will return my calls. This has gone on since 9/05 and it is 4/06! Who can I contact to help me? My insurance company said they can do nothing and I cannot afford an attorney. I can not even find a law on the books that tells me they have to honor my request.
    Which leads me to believe that if I pay for my services up front out of my pocket I do not get a discount, but if my insurance company pays it then I get the discount?

    I would be grateful for any direction or information
    Jo


    Sue the bad people in small claims court.
    There are two rules for success:

    (1) Never tell everything you know.
  4. #4
    beaufort is offline Junior Member
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    If the health insurance company is providing the discount, it is up to them to resolve your problem. They are putting the burden to acquire additional funds on you. I would contact the state insurance commission in the state you live and provide them with the information neccessary to file a complaint. They in fact, regulate every insurance company doing business there.
  5. #5
    somarco is offline Member
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    The carrier does not "provide" the discount (except in rare situations). Any fee negotiation takes place between the provider and the MCO, not the carrier.

    And it is technically not a discount, but an agreement whereby the provider agrees to accept as payment in full a predetermined amount for specific procedures.

    In this case, the provider has decided not to accept assignment of benefits, which is their prerogative.

    If the provider does in fact have a contract with an MCO that also contracts with the carrier, that provider is in violation of his/her contract if they are billing in excess of the contractual fee. As Senior Judge has indicated, the provider can be sued in small claims court if the patient has the proof to substantiate their claim of excess billing.
  6. #6
    beaufort is offline Junior Member
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    Quote Originally Posted by CRAFTMASTERS
    What is the name of your state? ILLINOIS
    I use our local Doctors Family Pratice for medical care. They are a Health Link provider with my insurance company. We have to pay for services at the time of service then I file the claim myself with my insurance company.
    I always send a copy of the cancelled check along with the documents the Doctors office give me to the insurance company. We have a health link discount and on my explanation of benefits it says "you need to request a refund from the provider on the discounted amount. Be sure to make a copy of this EOB and send it in with your refund request"

    Doctors Family Pratice has not refunded any of my request and I am owed almost $2,000.00. I have called and called and no one will return my calls. This has gone on since 9/05 and it is 4/06! Who can I contact to help me? My insurance company said they can do nothing and I cannot afford an attorney. I can not even find a law on the books that tells me they have to honor my request.
    Which leads me to believe that if I pay for my services up front out of my pocket I do not get a discount, but if my insurance company pays it then I get the discount?

    I would be grateful for any direction or information
    Jo
    I think she's interested in how to resolve her problem, not the intricacies of insurance.
    Last edited by beaufort; 04-28-2006 at 09:13 PM.
  7. #7
    somarco is offline Member
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    I understand your position, however your advice was not only incorrect but futile.

    If the health insurance company is providing the discount, it is up to them to resolve your problem.
    The carrier is not a party to solving this problem.
  8. #8
    averad is offline Member
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    Quote Originally Posted by somarco
    I understand your position, however your advice was not only incorrect but futile.

    The carrier is not a party to solving this problem.
    Actually if the provider is not accepting a write off the insurance carriers provider affairs should get involved. The Insurance carrier cannot make the provider send money to the member however they can pull the payment or a portion of the payment.

    Its a contracting issue because they are failing to take a contracted write off.
  9. #9
    somarco is offline Member
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    Providers do not (except in rare situations) contract with providers for services, nor do providers negotiate with carriers regarding fee schedules. That arrangement is almost always between the provider and the MCO. Managed care organizations are the ones who hold the key to what is accepted by providers as full payment.

    If the provider is not honoring their contract with the MCO then that is an issue between those two parties. The carriers obligation is to pay the claim according to the insurance contract and at a level as determined by the MCO based on coding. It appears the carrier has held up their end of the arrangement and are now out of the picture.

    Since the provider is not accepting assignment there is nothing for the carrier to withhold. If the carrier did "pull the payment or a portion of the payment" the provider is not the one being punished for non-compliance. Pulling a payment on this claim will only injure the insured.

    In this case, at least as outlined so far, the insured did their part, as did the carrier. The only one not playing by the rules is the provider. Since the provider is not being paid directly by the carrier there is no downside to the provider unless the patient pursues a legal remedy.
  10. #10
    averad is offline Member
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    Quote Originally Posted by somarco
    Providers do not (except in rare situations) contract with providers for services, nor do providers negotiate with carriers regarding fee schedules. That arrangement is almost always between the provider and the MCO. Managed care organizations are the ones who hold the key to what is accepted by providers as full payment.

    If the provider is not honoring their contract with the MCO then that is an issue between those two parties. The carriers obligation is to pay the claim according to the insurance contract and at a level as determined by the MCO based on coding. It appears the carrier has held up their end of the arrangement and are now out of the picture.

    Since the provider is not accepting assignment there is nothing for the carrier to withhold. If the carrier did "pull the payment or a portion of the payment" the provider is not the one being punished for non-compliance. Pulling a payment on this claim will only injure the insured.

    In this case, at least as outlined so far, the insured did their part, as did the carrier. The only one not playing by the rules is the provider. Since the provider is not being paid directly by the carrier there is no downside to the provider unless the patient pursues a legal remedy.
    Who said anything about providers contracting with other providers (and they do like labs)?

    If a provider affairs rep at BCBS gets involved they can use their contract with the provider to usually work it out. All that needs to be done is a review of the claim with the provider, member and provider rep on a conference call.

    And Somarco that_s the worst customer service (sorry can't help yah), try a first call resolution mind set from now on (take that extra step for the member).
    Last edited by averad; 04-29-2006 at 08:46 AM.
  11. #11
    somarco is offline Member
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    THIS provider does not have a contract with the carrier.

    What part of this situation are you having difficulty in following?
  12. #12
    averad is offline Member
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    Quote Originally Posted by CRAFTMASTERS
    they are a Health Link provider with my insurance company.
    The OP stated they are contracted.
  13. #13
    justalayman is offline Senior Member
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    Quote Originally Posted by somarco
    THIS provider does not have a contract with the carrier.

    What part of this situation are you having difficulty in following?
    If there was an EOB with a "discounted amount", this alone would infer there is a contractual agreement involved. Carriers do not have discounts with non-contractual providers.
    or;
    BCBS needs to revisit this billing and re-issue an EOB with figures that would reflect a non-contactual agreement (if applicable) and pay accordingly.

    BCBS needs to get back into this one.
  14. #14
    somarco is offline Member
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    I doubt the OP understands the contractual relationship between providers and PPO networks. Most people, such as yourself, assume a contract exists directly between providers and carriers when in fact it usually does not. Further, when I read the OP's statement is says NOTHING about a contract between the provider and the carrier. It does say the provider is a "Health Link provider" which may imply there is a direct relationship but does not clearly state. More likely, the provider has contracted with a PPO network who has in turn rented those relationships to the carrier.

    You may think you know how these manage care relationships are structured but your comments indicate you actually do not know.

    Beyond that, the OP has also stated the provider receives payment from the patient, not the carrier.

    A salient point you still have missed.
  15. #15
    somarco is offline Member
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    If there was an EOB with a "discounted amount", this alone would infer there is a contractual agreement involved. Carriers do not have discounts with non-contractual providers
    Carriers do not have discounts.

    PPO networks (MCO's) are the ones who hold the contract with the provider.

    Inferences are fine but mean nothing, particularly in this case.

    Health Link has discharged THEIR liability when they paid the claim. This is now an issue between the patient and the provider.

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