Overpayments to Healthcare Providers

[MichaelJ]

@Corpuschristi thank you for your responses, much appreciated.

 

[MichaelJ]

@leevena shame on me? You repeatedly made assumptions that were either contradictory to what I wrote or that you pulled out of thin air (like when you decided my procedures weren't medically necessary). Your responses weren't just unhelpful, they were incredibly frustrating.

As I am asking for help you have no obligation to respond to my initial question, but quite frankly if you aren't going to read what I wrote thoroughly I'd much rather you didn't respond at all. Stop assuming the person asking the question is wrong and/or doesn't know what they're talking about. Read what they wrote and answer the actual question they asked.

Shame on you.

 

[somarco]

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

@MichaelJ if I read this thread correctly, your ER visit came AFTER the PT sessions.

Since PT sessions were initially denied by the carrier the fact that you satisfied the deductible later in the year does not mean your claims would be adjudicated retroactively AS IF your deductible had been satisfied.

Your responsibility for PT claims is the repriced amount of APPROVED claims.

Claims that were NEVER approved, even after appeal, are not covered by the carrier, and not discounted.

 

[MichaelJ]

@somarco that makes sense, thanks for the input.

 

[somarco]

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,

@MichaelJ services WERE rendered so you ARE responsible for paying the provider. The only thing in question is HOW much the provider is due.

APPROVED claims (including those approved on appeal) mean your responsibility to the provider is the adjudicated amount. This of course assumes you received service from a par provider.

Claims denied or claims from a non-par provider are different. You owe the provider whatever they bill unless you can negotiate a lesser fee.

Regarding pre-certification (pre-authorization) the provider is not necessarily at fault if carrier approval was not obtained. Too many ways to fall through the cracks. Pre-cert/authorization is actually the patient responsibility. Same applies to using non-par providers.

Managed care (mangled care) is a boondoggle. So glad I am no longer involved in these fights.

 

[MichaelJ]

Pre-cert/authorization is actually the patient responsibility.

Gotcha, that's a key point to know. Thanks!

 

[leevena]

@leevena shame on me? You repeatedly made assumptions that were either contradictory to what I wrote or that you pulled out of thin air (like when you decided my procedures weren't medically necessary). Your responses weren't just unhelpful, they were incredibly frustrating.

As I am asking for help you have no obligation to respond to my initial question, but quite frankly if you aren't going to read what I wrote thoroughly I'd much rather you didn't respond at all. Stop assuming the person asking the question is wrong and/or doesn't know what they're talking about. Read what they wrote and answer the actual question they asked.

Shame on you.

Yet I did answer your question, the same answer the others gave you.

 

[somarco]

@MichaelJ as if this is not confusing enough, here is one other thing.

Claims initially denied due to lack of pre-authorization MAY eventually be paid on appeal. If the provider JUSTIFIES the claim as medically necessary and/or cost efficient, the carrier MAY pay those claims.

A procedure/test may be medically necessary but still be denied by the carrier if a less expensive procedure would have produced the same results.

 

[MichaelJ]

Yet I did answer your question, the same answer the others gave you.

@leevena they happened to come to the same conclusion as you but they arrived at it by reading my posts and not randomly altering information about the situation. Every one of your posts you made some (usually multiple) bizarre assumptions that made what you were saying completely irrelevant to me.

Say I post a question asking what 2+2 is, and you respond with 5-1=4. That's not a helpful answer. When someone else helpfully responds and says 2+2=4, that doesn't suddenly make your answer useful, just because it's the same number. Just because the helpful people also told me I'm responsible for the cost doesn't change anything I said about your answers being unhelpful and frustrating.