Overpayments to Healthcare Providers

[MichaelJ]

Hello, I have a question with regards to recouping payment from a healthcare provider. I had a high deductible health plan in 2019. I had to visit a physical therapist for an arm issue, so I got a referral from my primary and started seeing the PT. At the time I was well below my deductible so at every visit I paid them the expected amount that they had agreed upon with United, assuming I would be responsible for 100% of the cost due to my deductible.

There were issues processing the claims, the provider appealed, and eventually United denied the claims due to lack of prior authorization. Apparently this is different than not having a referral and is the provider's fault, so United deemed that my responsibility for these visits was $0.

In the meantime I had an ER visit in December that put me over my deductible, even though of course the payments I made to the PT did not count towards my deductible. Additionally the PT has removed the bills for these visits from my account (they initially tried to bill me the difference between what I paid and the full amount they would charge if I didn't have insurance).

1. Due to the fact that United deemed my responsibility to be $0, should the provider pay me back the full amount I paid for those visits?
2. If not, am I entitled at least to the difference between what I paid and what I should have paid? Given I hit my deductible I should have paid a 10% coinsurance, which is significantly less than what I did pay for each visit.
3. If I am entitled to a repayment, is there a legal process for claiming this, or do I simply contact their billing department and hope for the best?

Thanks in advance to anyone who has any helpful insight on this issue.

 

[leevena]

Prior authorization and referral are different. A referral is just that, you are being referred to Dr. Jones. Prior authorization is a process whereby the provider obtains approval for the service to be covered by the plan. It appears to me that your PT expenses were denied due to lack of prior authorization. Then the PT appealed and was denied, is this true? If true, then your deductible is $0.

What do you mean by “the pt has removed my bills from the account”, what account? The PT cannot remove anything from your insurance.

Your question #1 does not make sense. If United deemed your responsibility to be $0, you would not owe anything.

If your PT services are not being covered by the United Plan, then you are responsible to pay them.

 

[MichaelJ]

Thanks for the response, hopefully I can clarify.

What do you mean by “the pt has removed my bills from the account”, what account? The PT cannot remove anything from your insurance.

They removed the bills from my account with them, so my account with the PT provider. Basically they just stopped trying to bill me for these visits, as they had been previously trying to charge me the difference between what I initially paid and the non-insurance amount.

Your question #1 does not make sense. If United deemed your responsibility to be $0, you would not owe anything.

That is exactly what I'm trying to confirm. The PT's appeal was denied due to lack of prior authorization, and United has the 'Amount I may owe provide' as $0 on the EOB. I spoke with a United rep and they confirmed that this means they do not consider me responsible for any part of the payment. BUT I already paid at the time of the visit, so what I'm trying to confirm is if this means the provider owes me back what I've already paid to them.

If your PT services are not being covered by the United Plan, then you are responsible to pay them.

So to clarify here, am I correct that there's a distinction between 'not being covered' and the claim being denied due to lack of prior authorization? As you stated above, if United deemed my responsibility to be $0 then I should owe nothing. United is not paying the claim, but it would have been covered had the provider followed the proper procedures. So I believe that means I am not responsible for paying them, is that correct?

 

[leevena]

Ignore the United rep and EOB. Your expenses with the pt are not an eligible expense with your health plan. The pt has not been paid by the carrier, you are responsible for those expenses.

It has nothing to do with whether proper procedures, the pt appealed it after they failed to follow proper procedures, and was denied. It appears your expenses were not medically necessary.

 

[MichaelJ]

The appeal was denied due to lack of prior authorization, not because the procedures were not medically necessary.

If I were responsible for the full payment then why did the provider remove the bills, wouldn't they still be trying to charge me the full amount that someone without insurance would be paying?

It's also worth noting that after around 10 visits the provider apparently obtained prior authorization and subsequent visits were covered, so at no point did the insurance decide my visits were not medically necessary.

 

[leevena]

I feel like there is more to the story. The expenses were finally authorized during the appeal process, which is standard. But I am confused by what you mean when you say the provider removed my bills.

Is the pt provider billing you for services? If yes, pay them or try to negotiate some number lower and pay that amount.

 

[MichaelJ]

Is the pt provider billing you for services? If yes, pay them or try to negotiate some number lower and pay that amount.

As I mentioned multiple times in my posts above I ALREADY PAID THEM. I am attempting to determine if they owe me based on the fact that what I paid them at the time of my visits is more than what I actually owe.

Again this is all in my previous posts, there is not "more to the story" but I will spell it all out again here.
1. At the time of the PT visits I paid their agreed upon amount with United, due to the fact that I had a HDHP, so the assumption was that whatever the allowed charge was, I would be responsible for all of it.
2. The provider submitted the bills to my insurance and they were denied.
3. The provider billed me for the full amount of the visits (i.e. the amount they charge to someone with no insurance) minus what I had already paid. I could see these bills online when I log in to the provider's website.
4. I asked the provider to resubmit the claims to United
5. They appealed, United denied the appeal on the grounds that they had not obtained prior authorization, United determined my responsibility for the visits is $0.
6. The bills for these visits (the bills I mention in step 3 here), were removed by the provider, i.e. I no longer see them when I log in to the provider's website.

So, I paid X to the provider. United says I owe $0. If the provider had done things correctly, since I did hit my deductible, my responsibility for each visit would be a number much smaller than X. Either way, I paid them more than what I should owe for these visits, so are they obligated to pay me back the difference?

 

[leevena]

So, by way of an example, is this what occurred?

PT visit is $100 per. United contracted at a discount, let’s say $80 per visit. Since you are covered by United, you are entitled to their discounted cost of $80, which is what you paid. Your cost should be the United discounted cost, which in this example is $80. If you paid more, ask for a refund. If you paid less, you owe them the difference.

 

[MichaelJ]

Right, this is exactly what happened.

So what you're saying is the amount that I paid, the $80 using your example, is the correct amount that I should owe. I'm having trouble understanding why that would be. If the provider had done things correctly, United would have paid them and I would only have been responsible for a 10% coinsurance. So in your example United would have paid them $72 and I would have paid them $8. Why should I have to pay that extra $72 per visit due to their mistake?

The actual amount is more than that and this was over the course of 10 visits, so you can probably understand why I would like to get the difference back., it adds up quickly. I pay a lot to have insurance in the first place, I hate to think that the if the provider screws up I'm legally obligated to pay for their mistake.

 

[leevena]

In your original post you stated that you have a high deductible health plan and that you have not satisfied the deductible amount. As such, you are responsible for the United discount cost of $80 per visit, using the above example. There should not be a $72 / $8 dollar split because you are responsible for the entire cost until the deductible is satisfied. From your post, I assumed you have not satisfied your deductible.

Had United done the right thing or not upfront is not relevantt. Had they received authorization up front your cost would have still been $80 per visit and their cost would have been $0 because of the deductible amount.

When a provider mistake is made, such as this one without prior authorization, they are allowed to appeal the denial. If the United denial was due to no pre-authorization, United and the PT would have worked it out during the appeal process and United would have accepted the pre-authorization retroactively. My experience tells me that there is some other reason the appeal was denied.