Can a therapist change your copay? doesn't your insurance company determine that?

Answer 1

If he no longer accepts assignment of benefits, which means that the insurance co no longer sets the reasonable amount, he can then charge you with the difference between his usual fee & what they will pay.This would result in an increased pmt for you. Let me give you an example:

1) He accepts assignment & he sends a bill for $100. The insurance co has determined that the reasonable fee is $80. They pay 80% of the reasonable fee which is $64. Your co-pay would be $16 - the diff between $80 & $64.

2) He no longer accepts asssignment which means that your insurance co no longer determines the reasonable fee. Your insurance co would still pay $64 (some pay less because he is no longer participating in assignment). You would then be responsible for the diff between $100 & $64 which makes your co-pay now $36.

If he still accepts assignment (call your ins co to find out) but is now charging you $36 then he is committing fraud & you should then report him to the ins.co.

Answer 2

A medical practice is never allowed to change your copay. They can work with you and allow you to make payment arrangements but they could be in a load of trouble if they charge the patient a total amount more or less than what the insurance policy dictates. With private insurance carriers this is considered abuse, and they risk not recieving reimbursement for services rendered or being booted from the plan all together. With federal plans such as TRIcare, Medicare, and Medicaid, this would be fraud and they could face being booted from the plans, huge fines, and even possible jail time in some cases.
Since you are using the term "copay" I assume you are covered under an HMO (Health Maintenance Organization- primary care physician required), or an EPO (Exclusive Provider Organization where you don't need a primary care physician). These plans require the patient to pay a set dollar amount for office visits, surgery, hospitalization, ect, called a copay. However, if the patient uses any facility that is not in the HMO network, coverage is usually denied, and the patient will be responsible for 100% of the costs.
Preferred Provider Orginazations(PPO), Medicare and similar plans require the patient to pay a percentage of the total medical bill, called co-insurance. These plans also cover the patient for more expenses when they use a physician or facility that is in the network, and cover less for out of network. Physicians can also bill for higher than the usual contracted amount in your health plan when you use an out of network provider since they do not participate in your plan and there is no contract on their end. The patient is responsible for these extra expenses.
In short, if you are covered by an HMO plan the provider is not allowed to change copays. If they charge less, the insurance company will also reimburse the provider less. If they charge more, it is considered abuse and should be reported as soon as possible to your insurance plan. There is usually a customer service number located on the back of your insurance card if you need to report abuse or if you have any questions.

Answer 3

a therapist can not change your copay...this amount is determined by your insurance company...they may be giving you a break...but if the ins co finds out, they are going to be in a whole load of trouble

Answer 4

Check with your insurance company to see what the amount they allow, if she is charging more than the allowable amount and is part of your insurances list of approved doctors (meaning they have agreed to lower fees with the insurance company) then you aren't required to pay the higher fee.

Good luck!

Answer 5

If you belong to a health maintenance organization, they negotiate the co pays. I would think the therapist is not allowed to change your co pay. Talk to your insurance carrier. This happened to me and I turned her in.

Answer 6

No physician can change your co-pay. They may not be satisfied with what your insurance pays them, but that is not your problem to deal with. If your physician is charging you more than your standardized co-pay I would report them ASAP.