Health 411: Doctor’s office took co-pay it shouldn’t have taken

I had a routine physical exam a couple of weeks ago and paid a $40 co-pay. I thought it was strange, so I called my insurance company. They said I should not have had to pay a co-pay for a routine physical exam.

I called the doctor’s office and they referred me to their billing department, who refused to refund me the co-pay until my insurer reimburses them for the full amount of the physical.

This doesn’t sound correct to me. They collected a co-pay that they should not have collected. Shouldn’t they refund my money and deal with the insurance company directly?

That’s right, says Amy Ford Keohane, president and chief marketing officer for the Philadelphia-based patient billing advocate organization MedClaims Liaison. If you went to see a provider who is contracted with your insurance company (all bets are off with out-of-network doctors), and your insurer does pay for routine physicals in full, then yes — the doctor’s office should immediately refund your money and deal directly with your insurer to collect payment.

You said you confirmed with your insurer that paying the $40 co-pay was a mistake. Still, sometimes consumers can misunderstand the nature of their doctor visit or how it’s been billed.

Here’s an example. President Obama’s Patient Protection and Affordable Care Act requires insurers to cover the full cost of a host of preventive services, with the patient not being responsible for either a co-pay (the fixed fee you pay to see the doctor) or co-insurance (the percentage of the bill you have to pay). But there are exceptions to that. Plans already in place when the law took effect on March 23, 2010, are considered “grandfathered” and are exempt.

Also, only preventive services are covered in full — and even if your appointment is originally preventive in nature, it could end up with a different billing depending on what happens while you’re there.

“If the patient goes in for a physical and in the midst of it discusses a complaint on, say, a foot injury, the visit no longer is preventative,” says Erin Moaratty, representative for the Hampton, Va.-based Patient Advocate Foundation. At that point, your appointment will be subject to co-pays, co-insurance and deductibles (the amount you pay before insurance kicks in and picks up the bills), as dictated by the rules of your plan.

To clarify exactly what transpired during your physical, Moaratty suggests you ask the doctor’s office and/or your insurance company for two codes: the CPT (Common Procedural Terminology) and diagnosis codes associated with your visit. These are assigned to every medical service and procedure and are used by healthcare providers to bill insurers. That will clear up any confusion that may exist about how the visit should have been billed.

Another tip: When dealing with your doctor’s billing office, you might get a better response to your request for your $40 by asking for a staff member higher up the chain. “Escalate to a supervisor. Some people don’t have the authority to make those kinds of decisions,” Moaratty says.

When talking to that supervisor, it’ll help if you are very clear on the facts about what is required of a doctor considered “in-network” by your insurer.

“If it’s a network provider, they’ve signed a contract,” says Nancy Metcalf, senior program editor with Consumer Reports. That contract says doctors can’t make you pay any more for your visit than your health plan says you have to.

By refusing to refund money it mistakenly collected, Metcalf says, the doctor’s office violated its contract with the insurance company. Just letting the office know you’re aware of that fact may be enough to prompt them to act.

If that doesn’t work, get your insurer involved.

“The health plan may be able to intercede on behalf of the patient to get a payment issue resolved, depending on the specific circumstance,” says Robert Zirkelbach, a spokesman for America’s Health Insurance Plans, an industry trade group.

And when you call your insurer, consider asking the customer service representative to initiate a three-way call with the doctor’s office to clarify the details of your plan. This approach usually clears things up, Moaratty says.

Still can’t get the doctor to send back your $40?

If you get your insurance through work, enlist the help of your benefits or human resources department. (Some companies hire outside vendors who will help employees deal with a variety of insurance problems.)

If all else fails, you can turn to your state’s department of insurance for assistance in filing a complaint. For contact information, go to the website for the National Assn. of Insurance Commissioners (www.naic.org) and click on the tab that says “States and Jurisdiction Map.”

Zamosky has been writing about how to access and pay for healthcare for more than 10 years.