In-Network doctor charges upfront and says he doesn't accept insurance

[Nokin]

What is the name of your state? Virignia

I am covered by BlueCrossBlueShield. A doctor that has a contract with BlueCross BlueShield and is in network for me (PPO) provided a service that is covered by my insurance with the plan I have with them. Before providing a service he informed me he does not accept any insurance, I had to sign a paper understanding that and that I have to pay him upfront. However, he did give me a receipt with a billing code and told me I could ask some reimbursement from my insurance. I submitted my claim to BCBS. BCBS told me since this doctor is in network for me they would only send a reimbursement check to the provider but I would receive a copy of an explanation.

The doctor charged 1095 dollars upfront. BCBS plan allowance for the service was 646.02. Insurance company covered 251.62 out of 646.02 leaving me with 394.40. Insurance company sent him a check for 251.62 which he says he is not going to cash (double billing). When I asked him to reimburse me the difference 700.60 since the true portion of what I owe him was 394.40 which I have already paid, he refused.

Can an in network doctor who has a contract with insurance company bypass his contractual obligations with insurance company and make a separate independent contract with the clients that are covered by the same insurance company?

 

[Zigner]

Talk to your insurance company, as this is dependent on their contract with the doctor.

 

[PayrollHRGuy]

There is no way he can have a contract with BCBS and not accept insurance. My bet is that he has terminated his contract with BCBS and news of it simply hasn't trickled through the BCBS system.

 

[Nokin]

Nope. He still has an ongoing contract with them. I called BCBS, their representative made a three way call. I was able to listen in the background while BCBS rep talked with him. He tried his same shenanigans by telling that I signed a paper beforehand that he doesn't accept insurance. BCBS told him his contract with insurance company overrides that. He kept talking in circles. In the end BCBS rep told the case would be forwarded to a case manager higher up for fraud. BCBS then told us we would not need to talk to him any longer. They would take care of the issue. Later that day he emailed us telling that he is willing to pay for the difference but that legally he is still correct and that he would win us in court any time. But since he is going on vacation he just doesn't want to deal with it any longer. I have yet to receive a check.

 

[xylene]

I have yet to receive a check.

How much time has passed?

You need to send the email to BCBS and continue to work your claim.

In the future don't sign an agreement to pay upfront for medical services. Don't agree to submit your own insurance claims. Go to a different normal doctor and pay copays after the service. Or if a specific doctor who has these crazy policies is the doctor you for some reason absolutely must see, just be prepared to self pay. Anything else is a recipe for disaster, as you have found.

I don't exactly think BCBS is exactly the good guy. They created the problem by sending YOUR payment to a doctor who was explicitly non-compliant with his contractual obligations... There is no way BCBS slavish rule following about matters where exercising the slightest bit of discrestion in the face of an already problematic doctor served ANYONES interest. No need to clap them like they saved your bacon when they are the ones who heated up the skillet.

 

[xylene]

And it IMHO, it is on BCBS to

1. Pay you. It doesn't really matter if the doctor got reimbursed, especially if he isn't promptly paying you. With the flimsiest pretenses why he can't, no less.

2. If they paid the doctor, it is on them to use their contractual powers to claw back that erroneous payment. You don't need to eat it because they stupidly sent money to a doctor who was getting network referrals but not accepting insurance. No sympathy for them, they should be eating this dispute not you.

 

[cbg]

I don't know who you talked to at BCBS but if you haven't already done so, you need to be talking to someone in their Provider Relations area, or whatever they call the area that deals with their contracts with the doctors.

 

[Nokin]

Hmm... BCBS sent the check to the doctor for what was HIS part of the reimbursement. I got a copy of explanation of benefits. The explanation of benefits basically states how much the insurance allows to be billed for that particular code, what part is the doctors reimbursement from the insurance company and how big is the portion that the patient has to pay. Now, since he got paid upfront (more than he was actually ever allowed to bill me for) he did not submit any claims. I submitted the claim. BCBS policy however is that reimbursements are only sent to service providers when they are in network, not patients. BCBS did not know that I had already paid him upfront until after they sent him the check for his portion. They assumed that he is doing it the way it is supposed to be done. That he performs a service, submits a bill to insurance, insurance sends him a check for his part of the compensation and he will then bill me for my portion of the service. BCBS only got notified of this when I called them and explained the situation. I wonder if BCBS contract with this doctor allows the doctor to make up a different contract with BCBS members. That is what essentially happened here. If he had wanted to provide services as an independent doctor, he should have terminated the BCBS contract first before treating us.

 

[PayrollHRGuy]

His contract and its status isn't really your concern.

You need to put everything that happened down on paper in a readable format and send it to BCBS Prover Relations. You can contact them first to make sure you send what they need.

 

[Nokin]

Well, after I talked with BCBS rep they said this matter will get forwarded to their case management unit where I should hear back within the next 21 days. I still have time. I am very new to all this. Coming from a country of universal healthcare I am extremely overwhelmed by system here in US. Thank you for everyone that took time to read this case and chime in.

 

[Shadowbunny]

Well, after I talked with BCBS rep they said this matter will get forwarded to their case management unit where I should hear back within the next 21 days. I still have time. I am very new to all this. Coming from a country of universal healthcare I am extremely overwhelmed by system here in US. Thank you for everyone that took time to read this case and chime in.

Please don't let this nut-case of a doctor set the standard for you. I've been dealing with medical insurance and providers in my job for almost 20 years -- and this is the FIRST time I've heard of a doctor pulling shenanigans like this!

 

[ajkroy]

In medical billing there is a form called the CMS-1500 (when filled out on paper and it is the basis for all online billing programs for outpatient billing). There is a box called 27A that indicates whether or not the provider "accepts assignment". This literally means that they accept the contract's terms for reimbursement and agrees to be paid by the insurer. If they do not accept the terms, they check "no" and charge the patient directly whatever they wish (and the insurer sends reimbursement to the patient). They cannot do both.

 

[justalayman]

In medical billing there is a form called the CMS-1500 (when filled out on paper and it is the basis for all online billing programs for outpatient billing). There is a box called 27A that indicates whether or not the provider "accepts assignment". This literally means that they accept the contract's terms for reimbursement and agrees to be paid by the insurer. If they do not accept the terms, they check "no" and charge the patient directly whatever they wish (and the insurer sends reimbursement to the patient). They cannot do both.

They haven’t done both. In fact they rejected the payment from bcbs which would make them compliant per your statements even though provider didn’t even file a claim. Bcbs appears to belive provider sent the claim form.


I don’t think then 27a is an option for in network providers. They have agreed to accept assignment by their preexisting contract with bcbs.

 

[ajkroy]

They haven’t done both. In fact they rejected the payment from bcbs which would make them compliant per your statements even though provider didn’t even file a claim. Bcbs appears to belive provider sent the claim form.


I don’t think then 27a is an option for in network providers. They have agreed to accept assignment by their preexisting contract with bcbs.

I missed the part where the patient billed the insurance, but 27A must have been checked yes for the reimbursement to go to the doctor. Otherwise, the money goes to the patient.

The form (or more specifically, the electronic equivalent) is for all outpatient billing, used almost exclusively by in-network providers.

 

[justalayman]

I missed the part where the patient billed the insurance, but 27A must have been checked yes for the reimbursement to go to the doctor. Otherwise, the money goes to the patient.

The form (or more specifically, the electronic equivalent) is for all outpatient billing, used almost exclusively by in-network providers.

Since when does a provider have a right to ignore their contract with bcbs?