Insurance/Medical

[KrisM241]

What is the name of your state? NJ

In 9/99 my husband went to a therapist that was included in his health plan and he continued until the fall of 2000.

In 12/01 both my huband and I went back to the same therapist - for a different reason until 3/02. We did not use all the visits that were authorized.

During the first period of time, it seems that the therapist assumed that the insurance was paying for the sessions but 16 sessions were not paid - the insurance says they were not authorized.

Two weeks ago (8/02) the therapists office contacted us and told us that we were responsible for paying 16 @ $150 for the unauthorized sessions. After discussing this, they agreed to accept 16 @ $60 which is what the insurance would have paid. We asked us them to provide the form that we had signed agreeing to pay what the insurance would not cover. They provided a form dated 12/01.

The letter from them states that if we do not pay the $960 lump sum immediately, they will send this to collection and will collect the $2400.

What should I do? Will I ultimately have to pay for their sloppy paperwork anyway, so just pay it and get it over with, or are we responsible for this if the agreement is dated 12/01 and the sessions were prior to that?

Kris

 

[cbg]

You are going to need to look at your policy.

Some policies require that YOU obtain pre-authorization for certain types of treatment. Generally, although not always, these are the policies where you can self-refer and do not need to have a primary care physician refer you to a specialist.

In other kinds of policies, generally but not always they kind where a primary care physician has to do all referrals, the doctor is responsible for obtaining pre-authorization.

Check out your policy (if you don't have a copy ask your employer or plan administrator - I'm assuming this is group coverage provide by your or your husband's employer) and then come back and I can help you further. It will make a difference how much responsibility you have.

 

[KrisM241]

Hi

I read through the policy and I am not going to pretend I understand this. Basically this is what I've gotten out of it:

My husband was free to go to an in- network or out -of-network doctor - each having different fee schedules. He did not need a referral from his primary care, but called Guardian for a list of therapists and he chose one they provided. The following is a quote "When you are obtaining services in-network your participating physician will request prior authorization for all elective admissions...if you are enrolled in the Charter POS it is your responsibility to obtain prior authorization for services from non-participating providers."

I'm not sure if this is what you are looking for. If not I will keep digging.



Kris

 

[cbg]

In both a PPO and a POS plan you are permitted to go to either in network or out of network providers. The difference is whether or not you have to get a primary care physician to authorize you to go to a specialist (and in some cases out of network care). Do you know whether you were on a PPO or a POS plan? It wasn't an HMO because HMO's don't permit out of network benefits except in emergencies. This is going to be key.

 

[KrisM241]

Hi

It is a POS plan. He did not have to get the referal from the primary care. He contacted Guardian directly for participating therapists.


Kris

 

[cbg]

It's unusual on a POS plan for you not to have to get PCP approval to go to specialists, even in-network. I'm not saying you can't be right; you can. It just is unusual. But I have never heard of a plan where the therapist's office would be responsible for obtaining the pre-auths; it would be either your responsibility or that of the PCP, depending on the plan. So this is probably not sloppy paperwork on the part of the therapist.

You need to contact the insurance carrier and ask them to show you where in the contract it says that there must be a pre-auth for in-network specialists. My best guess, assuming that you are correct and that on your policy pre-auth is only needed for non-network providers, is that MOST of the plans do require such a pre-auth, and they have somehow missed the fact that you are under the one plan that is an exception. If that is the case, once they have it squared away they should make payment without any problems.

If by some strange chance this plan does require the specialist, rather than the PCP, to obtain pre-authorization, then the therapist's office is out of luck and the insurance carrier will help you work it out with them. For the carrier I worked for the department to contact for that was called Provider Relations; it may be called something different with your carrier.

If it should happen that somehow you missed a clause somewhere in the contract that does make it your responsibility to obtain pre-authorization, you are out of luck and will have to go ahead and make payment. It's up to you, but you might want to consider making payment anyway just to avoid collection, and get reimbursed when this is straightened out.

Let me know if anything is unclear or if you have any other questions.

 

[KrisM241]

Hi

I don't have questions but I have more information. All of the approvals from the insurance company (I've acquired copies from the therapist) state "your provider will request the sessions".

That prompted me to call the Insurance company. I did not get far but I was told the provider knows what the plan benefits are should not be charging us for their error. They are filing a complaint which I was lead to believe was more than "just" a complaint - it's an investigation. I don't know what this means.

At this point it seems that I am about to be caught in the cross fire between the provider and the insurance.

Kris

 

[cbg]

Actually, it sounds to me as if you may have one of those rare policies where the specialist, as opposed to the PCP, is required to obtain the authorizations, and the insurance carrier is now going to take up your banner and fight the battle for you. This is what's supposed to happen in this case, so just stay in touch with the carrier and they'll deal with it. If the provider is supposed to obtain authorizations and they don't, generally you can't be held responsible for the payments, so this is a really good thing for you.

 

[KrisM241]

It would be great if that was what was happening, but what prompted my call to the carrier was that the authorizations were in hand. They had authorized more sessions than he used.

I can only surmise that the authorizations don't mean anything because the number of session exceeded the allowance and the carrier is saying that the provider knew the plan limits. This is where it gets fuzzy for me.

In any event they said they would get back to me in days. Would you like an update at that time?

Kris

 

[cbg]

Yes, let me know how it goes and if you have any additional questions at that time, I'll try to help.