The Forestry Forum

Health and Safety => Health and Safety => Topic started by: Don P on January 01, 2018, 07:36:23 PM

Title: Insurance and PT
Post by: Don P on January 01, 2018, 07:36:23 PM
This may just be me ranting and it happens to everyone.
I had my right shoulder repaired 5 or 6 years ago, insurance covered what it covers on the surgery. I did physical therapy and after it was all done and said I ended up being billed about 3 grand for pt that insurance said wasn't covered.

I went in in Sept this year for the other one and when it came time to do pt I specifically asked if the pt folks could work with my insurance company. They checked and said it was no problem. I get back from Christmas and there is the thick letter denying around half of the bill. They waited until I was done both times not during the months of pt.

As far as I'm concerned this is bait and switch, if not illegal it sure is unethical. If I hadn't fired myself from their care this would have gone into many thousands, as it is it looks to be a healthy few. Have any of you all run into this and if so, how did you deal with it?
Title: Re: Insurance and PT
Post by: loganworks2 on January 01, 2018, 11:46:16 PM
Is it a bill from the insurance company or from the physical therapist?  I know in with my insurance I only have a small copay for each visit. If it is a bill from the therapist I would not pay it and have them take it up with your insurance co since they said they would accept your insurance.
Title: Re: Insurance and PT
Post by: clearcut on January 02, 2018, 01:11:15 AM
This is illegal in some states, but apparently not Virginia. It is immoral and unethical everywhere.

You need to find out specifically why the PT was not covered.

Was the PT provider in your insurer's network? Did you get your approval in writing? Who said you were covered, the PT office or your insurance? If the PT office said you were covered, ask them to accept your insurance's payment. If you insurance said you were covered, get them to negotiate with the PT office.

There are a number of articles on steps you can take to fight surprise medical bills. Google "How to Fight Surprise Medical Bills" for strategies. Most suggest disputing the charges in writing, and not paying until you reach an agreement. Once you pay, you have no leverage.

You need to gather all of the documentation, check out what the laws in your state say, and get on the phone. Document all calls. You may have to file a complaint with the Virginia Bureau of Insurance.

Best of luck with a difficult situation.
Title: Re: Insurance and PT
Post by: YellowHammer on January 02, 2018, 02:31:58 AM
I had a total hip replacement and PT was an important and lengthy part pre and post op and was fully covered, minus $25 copay.  My insurance company required that my Dr Office provide a detailed form letter to the insurance company and the PT company stating how much of exactly what PT was required.  I also received a copy.  All PT had to fit within the guidelines of the the hip surgery. For example, I complained my knee was hurting on one visit and they said they couldn't do anything about it until I had a Dr exam and subsequent approval to get PT on it specifically.  It was all very formal and by the book.  The PT office would not even start the program until the insurance was approved up front as to the type of PT, the duration of each visit, the frequency and the number of weeks allowed.  They even let me know how much coverage of PT I had remaining, sort of like a countdown. 

I would look into your matter more thoroughly and see exactly what happened. 
Title: Re: Insurance and PT
Post by: DPatton on January 04, 2018, 11:23:42 PM

Don P,

 I can sure understand your frustration. I get so sick and tired of getting the run around from the health providers,their billing companies/ and insurance providers. If iím In need of getting something done beyond just a regular Dr. visit I contact my provider directly and check for coverage of the procedure. My insurance provider actually requires pre-verification.
   Donít ask me how I learned to do this  8) 8) 8)  but I always request a confirmation of coverage and even go as far as keeping a written record of my call date and time, along with names and confirmation information that I receive. Itís a real PITA but it does seem to have helped me get proper coverage from my insurance provider.
   Another big rip off I have run into in the past  >:( >:( >:( is the healthcare providers billing code procedure errors. More than once I have had to contact a healthcare provider because their billing agency has used an incorrect billing code for a procedure that my insurance provide would cover, had they used the correct code.
   I did have two procedures this past year from a healthcare provider who did an extrordinary job of confirming my coverage and getting written pre approval from my insurance provider. This was something new to me and impressed me that they made this pre procedure effort to protect themselves as well as me. However long story short, I no longer trust what healthcare providers say about coverage unless they get it in writing. As much as I donít like it, I have to take the time to do the pre approval of coverage myself or expect to get the shaft later.
Title: Re: Insurance and PT
Post by: Don P on January 05, 2018, 12:18:54 AM
Thanks for the responses guys, I do appreciate it. Guess it's obvious I'm ignoring the stack on the desk right now, heck maybe it'll catch fire and go away  :D
I checked prior to surgery with the insurance company. The surgeon and staff checked and the pt folks checked but in the end I signed the forms that say I'm responsible.
Thus far I've just received the statement from the insurance company but no bills yet. I can't make heads or tails of the statements. I went to one company for PT, the codes all look similar and yet one session will be denied due to out of network and another was paid because it was in network. The sessions averaged around $690 each and the insurance negotiated them down to around $60 each. The ones I owe on are of course saying I owe the $690 each, nuts I can't seem to finish that line politely  :D. There was a copay which I took care of at each visit and I used only about half of the sessions that were allowed. I'm going to wait and see what the bills look like when they come in. I've been down since Sept and don't expect to be able to do very much till March, so there isn't a big hurry for resolution on my end, they might not be happy but they'll just have to wait.
Title: Re: Insurance and PT
Post by: coxy on January 05, 2018, 08:36:36 PM
check and make shur they didn't get the money from your insurance co and are not just sending you a bill to see if you pay more I had this happen to me after back surgery the pt did some stumbling of words and back peddling they got out of some how I was not happy about it was hoping they shut them down  >:(
Title: Re: Insurance and PT
Post by: clearcut on January 05, 2018, 09:17:46 PM
What might have happened is the PT office accepted your insurance, but the actual physical therapist that worked specially with you was out of network.

I had a similar case with an MRI. The facility and technician that performed the MRI were in network and pre-approved. The radiologist that read the MRI was out of network, and I was charged an huge amount extra.

In this case I put up a fuss in that there was no emergency and an in-network radiologist could have read the MRI. They knew which insurance was involved (pre-approved) and an out of network provider was unnecessary. They eventually backed down.

Good luck.
Title: Re: Insurance and PT
Post by: DPatton on January 05, 2018, 10:21:07 PM
That B.S. would not go over well with me. Glad to hear you were able to get it resolved. Iím affraid that would light my short fuse something terrible.
Title: Re: Insurance and PT
Post by: doctorb on January 07, 2018, 11:12:58 AM
Most of the time, this PT / insurance issue that is so frustrating originates from what is called "balance billing."  So the PT folks say they take your insurance.  Great.  The PT folks may even be part of your insurance coverage plan.  Also great.  But the PT office, and every other billing medical service including lab work, doctor's visits, dentists, x-rays, etc., bills more than the insurance company has agreed to pay.  When the PT office sends you a bill for something you thought was covered, they are usually "balance billing", that is, they are billing you for the portion of THEIR bill (the balance) that was not covered by the insurance company.  In most cases, when the provider (in this case the PT office) is within your insurance plan, there is no balance billing.  You only pay a co-pay.  If you go outside of your plan, watch out, because the rules of the game change drastically and the insurance carrier will leave you at the mercy of the medical provider because you decided to leave their system of care.  Even within your medical insurance system, a referral from your primary care doc or a letter of medical necessity for the service are often necessary.  Every insurance is different in this regard.

As has been said, depending upon where you live, balance billing can be perfectly legal, or totally against the law.  So the question you need to ask, next time you are trying to assure that your insurance pays for the service provided is NOT, "Do you take my insurance?" but "Do you balance bill the difference between what my insurance company pays you and your original bill?"

The whole system is completely mad.