by east30s » Sat Nov 28, 2009 01:21 pm
My insurance pays 50% of my mental health therapy sessions(im in nyc).....my doctor has agreed to bill his standard rate to the insurance company ie $150 per hour ...the insurance would pay $75 to my doctor and since i cant really afford to pay $75(ie remaining 50%) my doctor has agreed to take $35 from me instead.......my doctor is a kind caring individual.....and i dont want this act of altruism to get anyone in trouble....is this legal, etc?
Posted: Sun Nov 29, 2009 10:57 pm Post Subject:
Trench....its not my deductible that would be lowered...its the copayment......Just wanted to ensure that the information you are providing is from a legal source OR is it hearsay? thanks for the response
Posted: Sun Nov 29, 2009 11:55 pm Post Subject:
Deductible/copay same difference. You are still paying your copay, only your doctor has lowered it. As long as he is not over charging your carrier to cover the difference and he is taking the loss, no harm no foul. If he is false billing your carrier to make up for the difference, that would be illegal.
Posted: Mon Nov 30, 2009 04:47 pm Post Subject:
Sorry, east30s, as an insurance expert, your coinsurance is NOT being lowered. You are the beneficiary of what's known as "balance billing." Coinsurance is purely what the insurance company contracts to pay. 50%, 60%, 70%, it doesn't matter -- you pay the "balance" after the insurer has met its responsibility.
If you're in an HMO or PPO, and use a network provider, the most you'll be responsible for is your portion of the 100% (30%, 40%, 50%) of the allowable charge the insurance company does not pay. Out of network, the rules are entirely different. Your provider may bill $150, and if the insurer pays $75, then the total amount is within their definition of "usual, customary, or reasonable." That your provider is willing to "waive" some of your remaining balance is his/her personal choice.
It has absolutely nothing to do with your coinsurance. It is not fraud, it is not a crime.
Posted: Mon Nov 30, 2009 06:36 pm Post Subject:
your coinsurance is NOT being lowered.
How is it not? His doctor presumably is not collecting the remaining 50% of the coinsurance and not presumably burying the difference and charging the carrier to make up for it, instead is taking the loss.
Posted: Mon Nov 30, 2009 09:44 pm Post Subject:
Technically the coinsurance is not being lowered….. Normally the insurance company keeps track of the coinsurance that the insured pays (both in an out of network) as there are maxs on both in and out of network. So in this case the insurance company is paying at 50% and the insured’s coinsurance is 50% (in the eyes of the insurance company)
As for the insured, they are paying less since the doctor is waiving the balance of the bill or a portion of the bill as someone stated above.
It’s just semantics, but bottom line the insured is paying less. Lab companies, LabCorp and Quest do it all the time for low balances (couple bucks). It’s not worth their time billing for small amounts. In this case the doctor is not billing the balance and is taking the loss to be nice.
Even if the doctor inflates his bill, it should not matter as also stated below your company is only going to pay 50% of usual and customary.... So if usual and customary is $150. they are going to pay $75.00. If the doctor charges 1 million they are only going to pay $75.
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