Medicare, Medicaid, Life and Health Insurance/claims


I take my son to an occupational therapiest weekly. I thought I was going to be paying $70/session. The therapist said to initially pay $30 upfront. Her office billed my insurance company. Eventually my insurance sent me a check for $81/session. The eob read that she charged $120 and the insurance covered $81. I was surprised it covered more than the $70/session. I asked if I should give that to her. She referred me to her biller who said probably not. I called the insurance company and asked who gets the $11. The insurance company said that my contract with the provider is a separate relationship and is between me and her. When I showed the eob to my provider she said I owed her the $81 and I should start paying a $40 payment upfront to cover the $120. I said I thought $70 per session was the deal, why is the cost getting larger? She said to talk to her biller. The biller emailed me a reply saying that the self pay is $70/session. Now that she knows the insurance covers more the self pay with be increased to $93/session.

Anyway I'm confused and want to make sure I am doing this right. I have decided to discontinue occupational therapy until I sort this out. Obviously I want to pay the least amount since he also has 2 other therapies a week.

How much do I owe her? Can she change the rate? How should I proceed?

Rosemary - my, I had to read this about 4 times to figure it out and it is still confusing.  Not knowing what type of insurance your son has, I'll explain in 'normal' terms.
Normally, insurance states you have a copay for a certain visit or treatment, and that's all you pay.  If the provider doesn't get the whole amount they bill the insurance company for, then that's between the provider and the insurance company.

I'm not sure why the insurance company sent you the $81, it should have been sent to the provider, unless you have some sort of indemnity plan.  But it should go to the provider.

As far as her changing the rate - I guess she can charge anything she wants, but will not always get it.

If this is not a real insurance policy, then you might want to self pay.

I hope this helps.

Medicare, Medicaid, Life and Health Insurance

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Cindy Hopp


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