Medical Reimbursement

[BubblyBrunette]

What is the name of your state (only U.S. law)? CA
I am the NCP and pay child support and travel for my son to my ex as they now live in OR.

We both carry medical insurance for him but they (insurance carriers) use my insurance first since my birthday comes before his.

My son sees a pediatrician, therapist & specialist for his Asperger's.

I've asked them to use doctor's that are within my network so that we only have to pay the co-payment.

His therapist is not in my network and when I told them that they needed to change due to this they refused and the therapist left me a voicemail message stating that my ex had his own insurance and that she would be billing through that. I've never gotten a bill even though I have seen plenty of EOB's over the last year where they billed though my insurance as the primary and they were declined for being out of network and I figured they needed that denial so they could bill his insurance.

Well I just now received a bill from them for this therapist for $1,200.00 asking me to pay 1/2.

Do I have a right to refuse since I told them that they needed to see a therapist within my network?

 

[LdiJ]

What is the name of your state (only U.S. law)? CA
I am the NCP and pay child support and travel for my son to my ex as they now live in OR.

We both carry medical insurance for him but they (insurance carriers) use my insurance first since my birthday comes before his.

My son sees a pediatrician, therapist & specialist for his Asperger's.

I've asked them to use doctor's that are within my network so that we only have to pay the co-payment.

His therapist is not in my network and when I told them that they needed to change due to this they refused and the therapist left me a voicemail message stating that my ex had his own insurance and that she would be billing through that. I've never gotten a bill even though I have seen plenty of EOB's over the last year where they billed though my insurance as the primary and they were declined for being out of network and I figured they needed that denial so they could bill his insurance.

Well I just now received a bill from them for this therapist for $1,200.00 asking me to pay 1/2.

Do I have a right to refuse since I told them that they needed to see a therapist within my network?

Maybe...possibly...maybe even probably..maybe not at all.

It really all depends on the overall details of the situation and your son's circumstances.

If your son's diagnosis was long ago, and your child was firmly established with his providers prior to the court orders, and it can be established that its in your son's best interest to remain with those providers, then possibly it would be considered to be unreasonable for you to ask that the providers be changed.

If you ex simply went outside of your network's providers for the initial diagnosis, or ongoing care, then it could be a completely different story.

In other words, its not necessarily a simple answer.

 

[Ohiogal]

Do you have joint legal custody? What does your court order state regarding medical decisions and medical providers? It is likely that you will have to pay a portion of the $1200.

 

[gr8rn]

I am fairly certain you have a case against paying any portion of this bill. It has to do with that voicemail message from the therapist stating she was going to bill through the exes insurance. Did you keep the voicemail? The therapist did not follow through as she stated she would and should have either offered to accept the out of network amount, or she should have done what she said she would do and bill the other insurance. The birthday rule doesn't necessarily have to be followed. In fact, there are other ways to calculate who's insurance is billed first.

Normally the oldest insurance is the one that is primary, unless either is a state insurance (medicaid) then medicaid is alway second to private insurance. And if the therapist had done that then she would have committed insurance fraud, which may be why she did what she did.

 

[BubblyBrunette]

We have joint legal and physical but he is primary now that they moved out of state in Jan 2007. We share the medical 50/50

He was using a different therapist in OR when they first moved there that was covered under my insurance and then changed to someone they found through their church when they didn't like the advice given by the initial therapist.

My insurance covered this new one's bills for the year of 2008 only because it was brought to my attention in Jan of 2009 that my insurance hadn't been paying and this birthday rule. (When my ex moved, he did not have a job the first year he lived there and didn't get insurance until 12/08. His wife has been on permanent disability so they were using state aide and that's probably why the birthday rule came into effect.) When I called my insurance in Jan of 2009, they told me that they would pay for 2008 only because I wasn't told about changing his primary provider from CA to the Dr. there in OR but from that point on, I had to use doctors within my network. At that point I conveyed all this to my ex and the therapist.

When my ex sent me the medical bills/co-pays to pay him my 1/2 I have never seen anything on it with this therapist. Not even the co-payment. So I figured that his insurance had been taking care of it as the therapist had indicated. I was quite shocked to now see this bill for all this time.

I may still have the voicemail and will have to check. I have changed house phones since then but may not have cleared it. I will retrieve it later today from the garage. I know I have my documented notes from that time that I made every call and who I spoke with.

My ex sent me another e-mail last night telling me they will continue using this therapist whether she's in my network or not and are expecting me to pay 1/2.

 

[LdiJ]

We have joint legal and physical but he is primary now that they moved out of state in Jan 2007. We share the medical 50/50

He was using a different therapist in OR when they first moved there that was covered under my insurance and then changed to someone they found through their church when they didn't like the advice given by the initial therapist.

My insurance covered this new one's bills for the year of 2008 only because it was brought to my attention in Jan of 2009 that my insurance hadn't been paying and this birthday rule. (When my ex moved, he did not have a job the first year he lived there and didn't get insurance until 12/08. His wife has been on permanent disability so they were using state aide and that's probably why the birthday rule came into effect.) When I called my insurance in Jan of 2009, they told me that they would pay for 2008 only because I wasn't told about changing his primary provider from CA to the Dr. there in OR but from that point on, I had to use doctors within my network. At that point I conveyed all this to my ex and the therapist.

When my ex sent me the medical bills/co-pays to pay him my 1/2 I have never seen anything on it with this therapist. Not even the co-payment. So I figured that his insurance had been taking care of it as the therapist had indicated. I was quite shocked to now see this bill for all this time.

I may still have the voicemail and will have to check. I have changed house phones since then but may not have cleared it. I will retrieve it later today from the garage. I know I have my documented notes from that time that I made every call and who I spoke with.

My ex sent me another e-mail last night telling me they will continue using this therapist whether she's in my network or not and are expecting me to pay 1/2.

That is not reasonable and a judge will not think that it is reasonable.

 

[Ohiogal]

That is not reasonable and a judge will not think that it is reasonable.

Actually a JUDGE very well MAY find that is reasonable depending on the relationship that the child has with the therapist. Where is your son on the autism spectrum? How does he handle changes? How successful has he been with this therapist? Many children with autism suffer severe setbacks when major changes are made -- changing therapists because the therapist is out of network may NOT be a good enough reason. How much is each session costing? How often does the child attend?

If there were concerns about Out of Network providers then quite frankly that should have been dealt with at the time of the divorce/initial custody hearing to prevent out of network providers from being used.


ETA: The other thing is why weren't you involved OP during all of 2009 with your child's therapy and whether the insurance was covering?

 

[BubblyBrunette]

Actually a JUDGE very well MAY find that is reasonable depending on the relationship that the child has with the therapist. Where is your son on the autism spectrum? How does he handle changes? How successful has he been with this therapist? Many children with autism suffer severe setbacks when major changes are made -- changing therapists because the therapist is out of network may NOT be a good enough reason. How much is each session costing? How often does the child attend?

If there were concerns about Out of Network providers then quite frankly that should have been dealt with at the time of the divorce/initial custody hearing to prevent out of network providers from being used.


ETA: The other thing is why weren't you involved OP during all of 2009 with your child's therapy and whether the insurance was covering?

We have a very long complicated history. My ex's wife is overly involved in the upbringing of our son and has been. I wish I had known about this site years ago as it wasn't until last August 2009 that I was finally able to get the court to keep her from any further contact with me.

I should let you know that I had been raising my son since he was 2 without my ex being very involved. It wasn't until he was in 7th grade and paying a lot of child support that he started trying to re-establish a relationship with him. He would go to his day care and talk to him about coming to live with him and his wife so he wouldn't have to go to the Y after school. My son really wanted to try living 50/50 so I eventually agreed and then six months into it, they dropped a bomb that they were moving to OR and my son had to choose who he wanted to live with. The therapist he was seeing at that time thought I should agree to let him go and try since he had just started having a place in my ex's life so I reluctantly agreed. We put wording in the court docs that if after six months my son/therapist in OR agreed he could come back here to CA if it was felt necessary.

I should also note that my son has threatened suicide in the past when he first moved to OR to be with them when he was very frustrated over a fight he had with SM (she had put him in the shower with all his clothes on in front of his little brothers). He had only been living there six months and then when he came here for the following summer we agreed that he would stay here with me and my ex let me enroll him in school and then a month into it even after our first IEP he came down while I was at work and took him from school by police escort as I didn't have Primary custody any longer. Although, I had filed but the date wasn't until the end of Oct. Then it was continued due to some fires that we had and my attorney's paralegals house burnt down. Then I had to pay for him to have his (son) own attorney. By the time we got back into court it was May and near the end of the school year and my son was no longer saying at that time he wanted to live with me and the judge didn't want to make a change at that time but told me that I was free to come back at any time.

My son is not real high on the spectrum but it does affect him and he's on meds. I have tried contacting this therapist several times and she has never returned my calls or anything. I was very upset when they fired the first one without my knowledge and they tried to get him fired because he thought my son should be back here in CA with me and sent me letters to use in court to that effect. Like I posted earlier, when I found out last Jan. 2009 that my insurance wasn't going to cover the therapist I told my ex and the therapist (via voicemail) that my insurance wasn't covering any longer and that we needed to find a new one. The therapist told me that they would bill through my ex's insurance. I never get copies of anything from my ex until they want me to pay for 1/2 of his medical tx and send me a bunch all at one time. It's happened only twice since they moved there and I send my 1/2 once I reconcile it. The therapist bills have never been included. My ex also said that this is the first time they too have received a bill. Her visits cost $125 and he goes every other week.

My ex just recently also discontinued use of his latest specialist that was treating him for his Aspergers because she too disagreed with their punishments of him (such as can't go to school until his chores are done, he's missed 10 days so far this year). The Dr. felt that that they needed to help him with his diagnosis and accept it rather than punish him for it. When I objected to them discontinuing treatment and put up a fight they did try to reinstate treatment but the doctor wrote an e-mail and copied me on it saying that she would rather stay fired and help families that truly want to work with her rather than against her. So now I've had to help them try to find a new doctor that treats Aspergers in their very small town that is within my network. He has a new appt. on the 20th. I do plan to call this doctor and ask that he discuss my sons case with his old doctor.

They have been simply doctor shopping whenever a doctor disagrees with their parenting style.

Financially, I have been wiped out of my savings and have just been trying to keep the peace so that we avoid having any further custody battles as he is getting closer to 18. I fly him home once a month and pay child support so it's taken it's toll on me.

Sorry this is such a long post and probably more info than you asked for but with 12 years of history, it's hard to cut it down.

 

[BubblyBrunette]

I just checked my old answering machine and do still have the voicemail from the therapist telling me that she will be billing through Dad's secondary insurance and that she has been trying to get on my insurances panel but it doesn't look good as they told her that it was closed.

I also found my 2/20/09 e-mail to dad explaining this and his response was that they will continue to use her.

So any suggestions on how I should respond further to him?

 

[Ohiogal]

I just checked my old answering machine and do still have the voicemail from the therapist telling me that she will be billing through Dad's secondary insurance and that she has been trying to get on my insurances panel but it doesn't look good as they told her that it was closed.

I also found my 2/20/09 e-mail to dad explaining this and his response was that they will continue to use her.

So any suggestions on how I should respond further to him?

Quite frankly you should have gone to court March 1, 2009 to force a change in therapists or force dad to be responsible for paying the out of network costs associated. Why did you wait until almost a year later? Why weren't you in touch with his therapist between February and now?

 

[BubblyBrunette]

Quite frankly you should have gone to court March 1, 2009 to force a change in therapists or force dad to be responsible for paying the out of network costs associated. Why did you wait until almost a year later? Why weren't you in touch with his therapist between February and now?

I guess because in March of 2009 I was dealing with his contempt of not putting my son on the plane for his spring break visit and that took over and went before the court in August 2009. Plus I was actively communicating with the doctor seeing him for his Asperger's all along.

This therapist wouldn't take my calls and I let it go feeling like they were going to tell her whatever they wanted anyway.

 

[Ohiogal]

I guess because in March of 2009 I was dealing with his contempt of not putting my son on the plane for his spring break visit and that took over and went before the court in August 2009. Plus I was actively communicating with the doctor seeing him for his Asperger's all along.

This therapist wouldn't take my calls and I let it go feeling like they were going to tell her whatever they wanted anyway.

That is an issue though. Because you KNEW dad was going to continue using that therapist. By not doing anything -- especially when you were court in August -- is going to be seen as though you consented.
ETA make sure that the therapist has billed your ex's insurance.

 

[BubblyBrunette]

That is an issue though. Because you KNEW dad was going to continue using that therapist. By not doing anything -- especially when you were court in August -- is going to be seen as though you consented.

I see what you're saying.

 

[Ohiogal]

I see what you're saying.

In case you didn't see my edit -- MAKE SURE THAT THE THERAPIST has billed your ex's insurance and ask for proof of that.

 

[BubblyBrunette]

In case you didn't see my edit -- MAKE SURE THAT THE THERAPIST has billed your ex's insurance and ask for proof of that.

Thanks. I did send him a e-mail earlier today asking for copies of all his EOB's from his insurance and sent him a print-out from mine. I will have to reconcile the bill from there.

I again asked him to work this out with me as we are to make decisions together for our son's medical and was again told that he will continue to see this therapist.