Overpayments to Healthcare Providers

[MichaelJ]

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.

As stated in my first post I did meet my deductible, so when the provider filed the appeal my deductible was paid in full.

The last EOB (as in the one most recently processed, since each claim was submitted more than once) lists the reason for denial as lack of prior authorization, so I don't see a reason to think it was anything else. Let's just say for the sake of argument that the EOB is correct, and the claims were denied due to lack of prior authorization. Had they been processed correctly, I would have owed $8, not $80. In that situation, where I definitely 100% should have only had to pay $8 had things been processed correctly, is the provider required to pay back the overpayment, since I paid them $80?

 

[leevena]

Actually, you did not meet your deductible. Because the PT expenses adjudicated denied, those expenses are not applied to your deductible because they are considered ineligible expenses. The carrier has no contractual responsibility to pay any of the PT claims. You are financially responsible to pay for the PT visits.

For sake of discussion, let’s assume the PT expenses were eligible, and assume you have not satisfied your deductible. The cost to you would be $80 per visit until such time as the eligible expenses submitted satisfied your deductible amount. The those dollars above the deductible amount would be paid according to the schedule of benefits, which could be a copay or a %.

Based on what you have presented here, you are financially responsible for the PT costs.

 

[MichaelJ]

I HAVE SATISFIED MY DEDUCTIBLE, THE ER VISIT ALONE COVERED THE ENTIRE DEDUCTIBLE.

 

[MichaelJ]

Can we assume for a second that I am not misunderstanding something or misrepresenting something and answer the actual question I am asking???

 

[leevena]

Your question was about the PT visits. They are not an eligible expense. Carrier has no responsibility to pay any of the PT costs

 

[MichaelJ]

Sigh...

Is there some other kind soul on this website who wouldn't mind actually reading what I wrote and answering my question? I would greatly appreciate it.

 

[Corpuschristi]

Let's say you had a fender bender on your car. Your annual deductable is $5000. The fender bender cost is $4000, but you found someone that would fix it and you paid cash without the insurance company knowing about the incident. A few months later you get into another major wreck and now your repair costs are $8000. You will still pay the $5000 deductable and the insurance company will pay $3000. The previous amount paid will not count toward your deductable because the insurance carrier never approved the initial $4000. Only prior authorized procedures count toward deductible. Think of it as a lesson learned and make sure everything is pre authorized.

 

[MichaelJ]

But that's not analogous to my situation, because the insurance does know about the visits. A more accurate comparison would be if the initial repair of $4000 was supposed to go through my insurance, but the repair shop screwed something up and the claim was denied. In that case I would think I would legally be able to go after the repair shop due to it being their error.

I'm not refusing to accept that I might just be screwed out of the money but so far every response has been a slight variation on my actual situation.

So plain and simple, if a claim is not paid due to a screw up on the provider's part, is the consumer responsible for the cost?

It would be really stupid if that is the case, but that doesn't make it impossible.

 

[Corpuschristi]

I don't work for insurance companies. I can view both sides of this case. It doesnt count If you don't get pre approved. Insurance carrier didn't pre approve so it doesn't count.

 

[leevena]

But that's not analogous to my situation, because the insurance does know about the visits. A more accurate comparison would be if the initial repair of $4000 was supposed to go through my insurance, but the repair shop screwed something up and the claim was denied. In that case I would think I would legally be able to go after the repair shop due to it being their error.

I'm not refusing to accept that I might just be screwed out of the money but so far every response has been a slight variation on my actual situation.

So plain and simple, if a claim is not paid due to a screw up on the provider's part, is the consumer responsible for the cost?

It would be really stupid if that is the case, but that doesn't make it impossible.

For the last time, YES. You are responsible for the cost.

And another thing. You came on this site for help, you did not like the answers given and your attitude changed, becoming angry and condescending. Shame on you.