Wiki Issue with getting a refund: Personal HELP!

Create Wiki
kpeterson15

kpeterson15

Networker
Messages
61
Location
Cape Coral, FL
Best answers
0
I was looking for someone to give me some advice about an issue I am having with an office for overcharging.

About 4 months ago, my boyfriend went to a gastroenterologist as a referral from an ER doctor. At this gastro office, they charged my boyfriend a consultation new patient moderate code fee which was about 176. About 2 months later, I was looking at his EOB, and I see they charged his insurance company as well but only for a new patient office visit. Per the insurance companies bill, we were only supposed to pay 123.

My question is, is it legal that they charged us the consultation fee but only charged the insurance company a new office visit fee? Do we have the right to tell them, they owe us the difference between the two fees? I understand is it only a 50 dollar difference, but to me, I believe we should only have to pay the 123 dollars, not the 175. Unfortunately, my boyfriend had no idea about insurance stuff so he just thought that is how you normally do it when it comes to having insurance. No, he doesn't have a copay either. I believe I know the answer, but I just want to make sure.

Also to add, the last time my boyfriend talked to the billing manager, she said that the consultation fee and the new patient fee are the same thing, and from my year and half of being in coding school, I am almost 99% sure they are different and the charge is obviously different. I just need someone to tell me I am not crazy because this office is making me very irritated. LOL.

I have read that many insurance companies will not pay for consultation codes because it is very hard to meet the necessary requirements of a consultation code.
 
Last edited:
If your boyfriend had insurance, why did he pay in full up front? (No judgement, legit question.) If he has a high-deductible plan, he does not have to pay until the insurance processes and he knows his responsibility for the submitted charges.

If the office considers a consult and a new patient visit to be the same, they should have them priced the same - and frankly, it doesn't matter how they view the codes. They aren't equal in type of service or RVU values. It appears to me that your boyfriend's insurance doesn't accept consult codes so the office submitted the new patient code instead - and they should have known this when providing the estimate or on check-out, depending on when they collected the money. They have billed his insurance for the lesser amount and I'm presuming they are in network, so there is a contractual write-off that they are obligated to take. The amount owed is based on the allowed amount for the billed service and they owe him the difference between the original amount collected and the actual patient responsibility on the EOB. If they claim there is no overpayment, make sure they have taken the full contractual write off per the insurance EOB.

If they still refuse to refund, I personally (in the same situation) would file a complaint with the insurance company.

Edited to add some additional thoughts & clarification :)
 
Let me make sure I have got this straight...You paid in full for the visit AND the insurance company paid in full? That's double dipping. Contact the insurance company, let them know that you paid in full for the visit at time of service. They will need proof of payment. The insurance company should have paid your boyfriend rather than the doctor's office. What should happen next is the insurance will request the payment back from the doctor's office and reimburse your boyfriend. If they do not, the doctor's office should refund you the entire amount paid...especially if they are contracted with said insurance.
 
No, I totally understand why your asking! He thought it was weird but he is not 100% insurance literate. He is 26 years old and never really had his own insurance or health problems at all. He told them he had insurance and even asked if that was the price with insurance and they told him yes. So, he just thought it was normal and paid. It wasn't until he had a follow-up visit, where he found out that what they did for that first visit was not what was suppose to happen and he did not need to pay upfront. We believe the receptionist had no idea what she was doing and charged him like he had no insurance even though he told her he did.

After that happened, I went through all the information( receipts, EOB, etc) and even found out they even overcharged us for the endoscopy by 400 dollars!! They made us pay 550 upfront, and still charged our insurance company the full price of the endoscopy, so they made a 430 dollar extra profit. So, that's when we called explained everything, and they said oh ya we owe you that money, and they still haven't paid us back and it's been 2 months. I was almost willing to let to 50 dollars go because it was a big hassle, but we just got a check in the mail from this office for 27.99......... Where is the rest of the 400?! So, now we are trying to get in touch with the manager again and ask what is going on. Now, I am fighting for all the money that is owed to us which I should of just done in the first place.

Well, they have them priced differently so apparently they are not the same thing and the billing manager has no idea what she is talking about. Haha. And yes they are in-network, and their allowed amount for the new office visit is 134. Thank you for your response. Now I know I wasn't crazy and they owe us the difference.

I will 100% tell them if we do not get our refund, the insurance company is going to be notified and I am sure that will give them the motivation to give us our money back.
 
podcoder70 said:
Let me make sure I have got this straight...You paid in full for the visit AND the insurance company paid in full? That's double dipping. Contact the insurance company, let them know that you paid in full for the visit at time of service. They will need proof of payment. The insurance company should have paid your boyfriend rather than the doctor's office. What should happen next is the insurance will request the payment back from the doctor's office and reimburse your boyfriend. If they do not, the doctor's office should refund you the entire amount paid...especially if they are contracted with said insurance.
Click to expand...
For the office visit, no the insurance company was billed but they decided to have this amount go towards his deductible, so we ended up having a bill of 123. So, between the 175 they charged us and the 123 we should of only paid, they owe us about 50 bucks for that visit. Also, after all this had happened, I found out they charged the full amount for his endoscopy to the insurance company even though they made us pay 550 bucks upfront. The insurance company paid 90% of the endoscopy and we should have only paid 103 dollars. We were extremely confused about why they did that, and we believe the receptionist had no idea what she was doing.
 
I have a sneaky suspicion that somebody knows exactly what they are doing. Send an email or letter to the doctors office, simple and short, with line item detail of what they owe you. Include the remit from the insurance company showing what "you owe". Say in the email/letter that you expect the refund by X date...give them a week. If you do not get a response, contact the insurance company and the medical board. I am all for collecting deductibles upfront, however, offices need to be quick about refunding ESPECIALLY when a patient requests it.
 
podcoder70 said:
I have a sneaky suspicion that somebody knows exactly what they are doing. Send an email or letter to the doctors office, simple and short, with line item detail of what they owe you. Include the remit from the insurance company showing what "you owe". Say in the email/letter that you expect the refund by X date...give them a week. If you do not get a response, contact the insurance company and the medical board. I am all for collecting deductibles upfront, however, offices need to be quick about refunding ESPECIALLY when a patient requests it.
Click to expand...
Thank you! I will do that. I am sure whoever it was definitely knew what they were doing, but I was trying to be nice and give the benefit of the doubt ;) Thank you for that information!
 
kpeterson15 said:
For the office visit, no the insurance company was billed but they decided to have this amount go towards his deductible, so we ended up having a bill of 123. So, between the 175 they charged us and the 123 we should of only paid, they owe us about 50 bucks for that visit. Also, after all this had happened, I found out they charged the full amount for his endoscopy to the insurance company even though they made us pay 550 bucks upfront. The insurance company paid 90% of the endoscopy and we should have only paid 103 dollars. We were extremely confused about why they did that, and we believe the receptionist had no idea what she was doing.
Click to expand...
If they knew he hadn't met his deductible, then it somewhat makes sense that they would ask him to pay an estimated deductible up front. That's not uncommon. But he clearly overpaid and they owe him the difference back.

Good luck. Sounds like you have an uphill battle!
 
Don't forget that some payers will not accept the consultation codes, after the 2005 elimination of these codes by CMS. So even though the original charge was a consultation, the biller may have had to later on submit a new patient code to the insurance. Although they're not the 'same thing', the consultation code is irrelevant for some payers. Still....your boyfriend is only responsible for the amount charged to his insurance less the payment and contracted adjustment (he would owe co-insurance, deductible or copayment, depending on the plan).

Many small, private practices will collect money up front, because they can't always afford to chase people for money that's later owed to them. Statistically, medical bills are the last bills paid by most Americans.....not to be judgmental, but that's been shown in studies. Your boyfriend's younger age may have played a part in their wanting to get the cash up front. Stinks, but there it is...... At any rate, yes the office got paid, and now owe your boyfriend the difference, and depending on how quickly their office gets the books settled, you may have to wait a few weeks. But if more than a month goes by, you may have to get aggressive. You can call the insurance company, but frankly, they're not going to get into the middle of your finances with the office, although they may make a courtesy call on your behalf. Usually they only step in if there's been a billing error. If the claim was paid and billed correctly, they are not going to get in the middle. I'd continue to call the office, and follow up with a certified letter....with a return receipt requested so you know they got it. You can 'threaten' to take the practice to small claims court, if you have proof of payment and insurance reimbursement, but it's unlikely to come to that. Most likely this is a small practice with a cash flow problem and they are taking their sweet time reimbursing you, but if you get noisy about it, they will settle up. Good luck.
 
Pam Brooks said:
Don't forget that some payers will not accept the consultation codes, after the 2005 elimination of these codes by CMS. So even though the original charge was a consultation, the biller may have had to later on submit a new patient code to the insurance. Although they're not the 'same thing', the consultation code is irrelevant for some payers. Still....your boyfriend is only responsible for the amount charged to his insurance less the payment and contracted adjustment (he would owe co-insurance, deductible or copayment, depending on the plan).

Many small, private practices will collect money up front, because they can't always afford to chase people for money that's later owed to them. Statistically, medical bills are the last bills paid by most Americans.....not to be judgmental, but that's been shown in studies. Your boyfriend's younger age may have played a part in their wanting to get the cash up front. Stinks, but there it is...... At any rate, yes the office got paid, and now owe your boyfriend the difference, and depending on how quickly their office gets the books settled, you may have to wait a few weeks. But if more than a month goes by, you may have to get aggressive. You can call the insurance company, but frankly, they're not going to get into the middle of your finances with the office, although they may make a courtesy call on your behalf. Usually they only step in if there's been a billing error. If the claim was paid and billed correctly, they are not going to get in the middle. I'd continue to call the office, and follow up with a certified letter....with a return receipt requested so you know they got it. You can 'threaten' to take the practice to small claims court, if you have proof of payment and insurance reimbursement, but it's unlikely to come to that. Most likely this is a small practice with a cash flow problem and they are taking their sweet time reimbursing you, but if you get noisy about it, they will settle up. Good luck.
Click to expand...
Thank you! I plan on becoming a pain now that it's been about 2 months since they said they would have us reimbursed. On top of that, we got a $27.99 check from them, and we have no idea what that is for since that is not near the amount they owe us.
 
You must log in or register to reply here.
Top