Doctor charged me AFTER I paid copay?

Question

I have PPO and I went to the dr and was told my insurance covered it so all I had to pay was $15 copay. Then, I just got a bill in the mail. My insurance didn't change or anything and they told me they found me in the system when I was there.

Can they get away with charging me the remaining balance of $190 eventhough they gave me their word that it was covered?

lumamiss.. horrible answer.

Thanks Dymond and Matpoor.. I think this is the case. I'm not moraly obligated to pay for the service if they TOLD me it was $15 which I gladly paid. There is probably a mixup or delay and I'm sure it's nothing..

Answer 1

It may take up to 8 weeks for your insurance to pay.I would contact the Doctor's office and find out if the insurance payment is still pending.

Answer 2

A doctor's office never knows that an insurance company will cover a service until it is billed and processed by the insurance company. That is because when a doctor's office tries to verify a patient's benefits it is only given an "estimate of benefits" and no benefit is guaranteed by the insurance company. Most offices have a financial policy that states as much and that you are ultimately responsible for all services rendered.
The office can get away with charging you because it is ultimately your responsibility to know about your insurance plan/policy. If you feel that you are being billed in error, call your insurance company.
Remember, if the doctor's office isn't paid by the insurance company, they still have to pay their bills too....and you have a moral obligation to pay for services that you received at the very least.

Answer 3

You might not like lunamiss's answer, but technically she's correct.

Your doctor's office doesn't know what you're going to be obligated to pay until the claim is processed by your insurance company. And ultimately its your responsibility to know your benefits and how they work.

If there were amounts applied to deductible, or services which you had to pay a percentage of that didn't fall under your $15 copay (ex - if you have to pay 20% for lab work, x-rays, diagnostic testing, etc.), you're still liable for those charges.

Once your insurance company has adjudicated the claim and you get an Explanation of Benefits processed correctly according to the terms of your insurance policy, you're liable for the charges. Period. Doesn't matter if you "thought" that you'd just have your $15 copay - the doctor's office doesn't quote your benefits to you, you're supposed to know them yourself.

If your insurance company hasn't paid the claim yet and you haven't yet received your explanation of benefits, don't pay the bill of course. It could just be that your insurance company hasn't finished processing the charges. But, if you already have your explanation of benefits and it says that you owe $190, then you owe $190.

Answer 4

LUNAMISS may not have the answer you want to here but she is right. It was a very good answer and very correct at that.

You may not think you are morally obligated to pay but you most certainly are legally obligated. Doctors office's get the copay at time of service. They can not bind coverage with your insurance company as they have no idea what your specific policy covers. They bill insurance as a courtesy to you. With that said I bet it is likely that your insurance just has not paid yet. But you are the one that has to figure it out. It is not your doctors responsibility.


Sorry - I am sure you don't like my answer either.

Answer 5

Copay rates are set by the insurance companies, not by the clinic. If the clinic has patients from different insurance companies and those insurance companies have different copay rates, then the patients must be charged different copay rates from each other, because they are each charged the copay rate of their respective insurance companies. For example, if one patient is from an insurance company with a $20 copay and another patient is from an insurance company with a $25 copay, then one patient is charged $20 and the other patient is charged $25.

Answer 6

don't tell someone that they gave you a horrible answer just because you didn't like it. lunamiss is absolutely correct. some doctors don't even file with the insurance company. you are expected to pay at time of service and then file the claim yourself for reimbursement.

the doctor provided a service to you and you are ultimately responsible to pay for that service. if the insurance company didn't pay the way you thought they should then you have a beef with the insurance company, not the doctor's office.

Answer 7

Yes. They don't have the authority to bind the insurance company to paying the bill.

You do, however, have an obligation to be sure that any medical providers get paid for services rendered.

Now, it's up to YOU to call the insurance company, to see why they didn't pay it, and to appeal the denial, if you got a denial.

Answer 8

Yes. A doctor will take whatever the PPO pays for the service and if the PPO doesn't cover the agreed upon charge, you are responsible for the remainder.

Answer 9

My question to you is...how much is your deductible? What did they do in your visit? The doctor office call might be only a $15 co-pay but anything they did during the visit like x-rays or lab work is subject to your deductible. Which means the insurance company wont pay for it until you meet your deductible.

Answer 10

YOur insurance is just slow like all the rest. They have to send it in several times before it gets paid sometimes for me.