$2K Medical bill - Assigned me out of network physical therapist

[ChipParkr]

State: New Jersey

I am seeking help to address a medical bill of ~2K dollars for 12 physical therapy visits from mid summer of 2023 to early 2024. Before starting visits, I had submitted all my insurance details to the front office of the facility and had them confirm that my insurance is accepted and what would be my co-pay. I was told that they accept the insurance and there is no co-pay. Now one might say that not having co-pay is a red flag but I have been to PT facilities before that waive co-pay maybe because what insurance pays them is good enough for them and they waive co-pay. I thought this was the same case.

After couple of weeks, I started getting the BoE statement from Aetna saying I might owe money for the treatment. Immediately I took it to the PT office and they said do not worry, ignore the BoE statements, your treatment is covered by the insurance. Fast forward almost 6 months in early Jan, they send me a bill of 2000 dollars. When I question it, they say the therapist that has been treating me is out-of-network!!! I was shocked and said your office shows up on Aetna portal as In-network but they tell me you were assigned to a out-of-network Dr. I am baffled why would they not assign me in-network therapist or atleast tell me upfront and the costs involved of working with a "out-of-network" PT in an "in-network" facility. My co-pay is 20 bucks and max I would had to pay was 240 dollars but now I am being slapped with $2000 bill.

Since there is no written communication about this and the facility is telling me since I received the treatment I owe the money and that I should go on a payment plan. I feel this is complete fraud as I would never had gone to the facility if they said the therapist was out-of-network. How can I fight this ? I don't want this this bill going to collections and maybe impact my credit score.

 

[LdiJ]

State: New Jersey

I am seeking help to address a medical bill of ~2K dollars for 12 physical therapy visits from mid summer of 2023 to early 2024. Before starting visits, I had submitted all my insurance details to the front office of the facility and had them confirm that my insurance is accepted and what would be my co-pay. I was told that they accept the insurance and there is no co-pay. Now one might say that not having co-pay is a red flag but I have been to PT facilities before that waive co-pay maybe because what insurance pays them is good enough for them and they waive co-pay. I thought this was the same case.

After couple of weeks, I started getting the BoE statement from Aetna saying I might owe money for the treatment. Immediately I took it to the PT office and they said do not worry, ignore the BoE statements, your treatment is covered by the insurance. Fast forward almost 6 months in early Jan, they send me a bill of 2000 dollars. When I question it, they say the therapist that has been treating me is out-of-network!!! I was shocked and said your office shows up on Aetna portal as In-network but they tell me you were assigned to a out-of-network Dr. I am baffled why would they not assign me in-network therapist or atleast tell me upfront and the costs involved of working with a "out-of-network" PT in an "in-network" facility. My co-pay is 20 bucks and max I would had to pay was 240 dollars but now I am being slapped with $2000 bill.

Since there is no written communication about this and the facility is telling me since I received the treatment I owe the money and that I should go on a payment plan. I feel this is complete fraud as I would never had gone to the facility if they said the therapist was out-of-network. How can I fight this ? I don't want this this bill going to collections and maybe impact my credit score.

Unfortunately, it is difficult to fight that sort of thing. You can state loudly and clearly to everyone that you can get to listen at the clinic that you never would have accepted their services had you known the therapist was not covered under your insurance, and that you feel that they have cheated you by not telling you that they assigned you to an out of network therapist. That may or may not (honestly closer to the not) work. The problem is that they don't agree with you they will simply send you to collections. If you actually ended up in front of a judge they might lose the case, but they are unlikely to do anything but send you to collections and keep harassing you until you cave and pay them.

Also, even though they verbally told you that it was covered, it is highly probable that they had you sign paperwork that indicated that it might not be covered by insurance and that you understood that you would be responsible for the bill if your insurance denied the claim.

I really does stink that medical providers get away with that sort of thing but it is really the fault of our entire medical system and how it works with insurance.

 

[cbg]

I worked for a major insurance company back before the internet, when you looked at paper lists to see whether a doctor or facility was in or out of network. Believe me when I tell you that those lists were out of date on the day they were printed. It is not outside the realm of possibility that at the time you began treatment they were in-network and dropped their affiliation at some point after that. It may or may not have been intentional; the pharmacy I use is currently in negotiations to renew their affiliation and is running into roadblocks. But it's not impossible.

Always, always, always confirm for yourself, directly with the insurance carrier, whether a doctor or facility is in network. Get the name of the person you speak to; write down their name, the date and time. That way you'll have some protection should something like this happen. Do not rely on the facility to do that check for you.

In the meantime, while I can't promise what result you'll get, you want to be talking to Aetna's Provider Relations area, or whatever they call their department that deals with the provider contracts. They're the best ones to sort out what to do when you have an out of network doctor at an in network facility.

 

[Bali Hai Again]

We are talking about organized crime made legal. The RICO Act should be applied.

 

[ChipParkr]

Thank you much Ldij, cbg for the enlightening insights. Going forward I am always going to insist the individual Dr/therapist treating me is IN-NETWORK.

Honestly for this case, I am willing to take it to the last fight because I know how many times I kept asking the clinic's front office about the EOBs I kept receiving from Aetna including even before starting the treatment.

Also have noticed that all the medical provider billing services conspicuously do not share their email where all these facts can be shared in written

 

[quincy]

Here is an Aetna resource link to help you deal with an unexpected medical bill: https://www.aetna.com/individuals-families/surprise-billing-resources.html

 

[Taxing Matters]

We are talking about organized crime made legal. The RICO Act should be applied.

I'm guessing you don't really understand the RICO act. That's not surprising. Few non lawyers have much knowledge about the activities that RICO targets and how it is enforced. The problem of the type the OP has isn't something that RICO covers. These problems come about because medical insurance and medical providers are jockeying all the time to strike the best deal. They also come about because humans are not perfect and things fall through the cracks. A few years ago I got the surprise of finding out my particular plan from my insurance wasn't in network for the health care system I use. All the other plans from this insurer had my health system in network. My one plan was the only one that didn't. It got missed when the insurance company and health system executed all the agreements for the year. I won't go into the long involved story but the short version is that I ended up having to pay $600 for an ambulance trip to transfer me between hospitals to get me to one that was in network. The lesson for me was to never ever assume that my renewal plan for the next year covers the hospitals and doctor in the health system I use. At least it only cost me $600 to be reminded of something that as a lawyer I already knew.

Now I always ask the insurance company and check the list of in network providers before I let the plan just automatically renew. People need to know the basic details of their policies so they don't make costly mistakes. Problems like are not RICO matters. They are just the problems we get dealing with huge insurance companies and health care network in a complicated medical care environment. As with most things, the consumer needs to understand what he or she is buying, whether its bread at the supermarket, a car at a car dealership, or a medical insurance place.

 

[Bali Hai Again]

The average working professional/non-professional doesn’t have the time or expertise to play this losing shell game with the medical profession. A healthy person/family pays thousands of dollars for health insurance and when it’s time for needed coverage they run into loopholes designed steal their money. It’s time to dismantle the system in this country and put something in place like the UK. It might take something like another Boston Tea Party.

 

[ChipParkr]

Today went to the same facility and requested for copy of all documents I had signed at the start and during my course of visits. Upon going through the copies, they have added a section about "out-of-network" provider and it has few bullet points stating this is a OON specialty provider and that I undertake any financial responsibility applicable to health care services of OON.

This is an utter and shameless scam which I seem to be a victim of; before even going to the facility I had called them specifically for my insurance verification providing all the details. They confirmed , I again asked them to reconfirm so that there are no issues going forward. I had also checked on Aetna portal and saw on of the PTs in the facility is in-network. My assumption was I would be assigned to this in-network therapist. In prior experiences, I have been told I will work with a PT but internally the facility manages by having you work with different PTs in the office.

I really need to find the right ways to expose this facility and their devious practices.

 

[Bali Hai Again]

https://www.cms.gov/files/document/nsa-keyprotections.pdf

First you have to convince someone you were scammed by the medical profession. Good luck with that.

When you are signed up for Medicare Part B your primary care provider will think up all kinds of tests and recommend you go to their specialist Dr. Buddies to get in on the take. Just so you know.

 

[ChipParkr]

In total I had 13 sessions. If they had assigned me in-network therapist had I gone to any in-network or I would have paid 260 bucks because my PT co-pay is $20.

But they decided to keep it under the radar and now been sent 2K bill. Why on earth would I have paid the difference, I would just gone to a in-network facility

 

[LdiJ]

In total I had 13 sessions. If they had assigned me in-network therapist had I gone to any in-network or I would have paid 260 bucks because my PT co-pay is $20.

But they decided to keep it under the radar and now been sent 2K bill. Why on earth would I have paid the difference, I would just gone to a in-network facility

Have you specifically told them that you would not have utilized their services if you had known that they were assigning you to an out of network therapist?

 

[quincy]

In total I had 13 sessions. If they had assigned me in-network therapist had I gone to any in-network or I would have paid 260 bucks because my PT co-pay is $20.

But they decided to keep it under the radar and now been sent 2K bill. Why on earth would I have paid the difference, I would just gone to a in-network facility

You could always contact your local media outlets and tell your story.

 

[LdiJ]

You could always contact your local media outlets and tell your story.

This is not a bad idea at all.

 

[quincy]

This is not a bad idea at all.

… especially since health insurers are loving the media attention they are currently receiving.