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Overpayments to (In-Network) Providers

Overpayments to in-network providers are more common than people realize. They are far more common with high deductible plans because provider offices become impatient waiting for a claim to be processed, then generating a bill and waiting for the patient to pay. But overpayments have occurred with my coverage too which is not a high deductible plan. My coverage is a PPO structured so that the patient pays a copayment for a visit. One would think that should be very straightforward but sometimes it is not.

The problem with any overpayment, of course, is that it can be a project to get a refund.

The best way to avoid this headache is to avoid overpaying but that means being familiar with your benefits. I saw my ophthalmologist in early January and my plan does not require that one meet the deductible for many types of visits. Instead, you owe a copayment. At that visit, I was asked to pay $124.45 when I believed I owed a $35 copayment. I chose to not be too assertive about being overcharged because I’ve been a patient for many years, it was a small amount, and I thought getting my money back would be straightforward.

When the claim was processed for this in-network provider, the explanation of benefits statement showed my patient responsibility as the $35 copayment. I called and spoke to the billing person in the office and was assured I’d receive a refund check. Several weeks later I called a second time, and the biller said she would remind the administrator to send a refund check. I stated then that I did not want to dispute the overcharge on my credit card but I would if I didn’t receive a refund. I ended up disputing the overcharge to the credit card company (something I’d never done) and to my delight the credit appeared on my next credit card statement.

My refund of $89.45 was not an amount you want to spend too much time on, of course. However, I am eager to share the journeys which substantiate these problematic practices! I was surprised that calling the credit card company was so much more effective than dealing with the practice. This practice is a local practice with two ophthalmologists. The refund should have been simple.

As familiar as I am with these issues, I almost goofed and overpaid an Anesthesiology bill associated with day surgery my husband had earlier this year. He had a fairly routine hernia repair. He received a bill from the Anesthesiologist for a small amount due, $77.34, which I promptly paid. However, that payment was not reflected on the next statement which we received several weeks later. I came close to paying but, fortunately, did not. Billing is outsourced to an organization in Philadelphia which handles many practices and providers and the effort to get a small refund back might not have been worth the effort.

In summary, please take the time to see that what the explanation of benefits statement says you owe, matches what you are billed and pay. Otherwise, you are at risk for overpaying medical bills. These were small amounts but they’re not always small. And, your exploration will unearth other issues. My husband’s surgery was a fairly short procedure done laparoscopically. I learned from reviewing the bills and benefits statements that both an anesthesiologist and a nurse anesthetist were in attendance and combined received double the payment the surgeon did. That seems odd, doesn’t it?

Ah – this may be a topic for a future video!

Please manage your claims and medical bills and encourage others to do so and to watch our videos. Thanks.