[fuzzys]

About 6 months ago I was travelling out of state when I got injured. It was not serious but I wanted to get checked out. I called my health insurance carrier and asked where I could be seen, preferably at a walk-in clinic. I was given the option of going to an Emergency Room, or an Urgent Care Clinic. I was advised my ER deductible is $100 and my Urgent Care deductible is $50. I said I would rather go to Urgent Care but was told the closest one to where I was staying was 70 miles away. Nonetheless, I went to this clinic to avoid having to go to an ER. At the time of my visit, I went into the Urgent Care clinic which was attached to the hospital. I paid my $50 co-pay. Several weeks later after returning home, I received a bill for $50, which stated it was for my co-pay. I wrote a letter back explaining I had already paid the co-pay and provided a copy of the check. A few weeks after that I got another bill, stating my co-pay was $100 and I still owed $50. My response was to send them a copy of my insurance card which shows the Urgent Care co-pay is $50. For the past 6 months we have been going back and forth. They still insist that I owe them another $50, and now they have turned me over to a collection agency. I have sent letters to my insurance company as well as the hospital itself and neither one has responded. Do I just give in and pay the $50 that I don't owe to avoid a mark on my credit, or should I keep fighting it? What is the best way to fight this?

[TexasParent]

I would contact your insurance company again by phone and explain the situation. It's seems obvious to me ( I work in Medical Billing ) that whatever you were initially told by your insurance is not how the claim was paid.

What I think happened was this:

1. You contacted your insurance and the agent said a $50 co-pay for the Urgent Care Clinic.

2. You went to the clinic and they either trusted your card or verified benefits and agreed that you only had to pay a $50 co-pay.

3. They sent the claim to the insurance and the claim came back paid, but said you had a $100 co-pay and now they are trying to collect the difference.

I would:

A) If your insurance company has a website and you can view your benefits on-line or if you have a policy handy. I would get it in hand showing that a Urgent Care Clinic visit should only be a $50 co-pay.

B) Get a copy of the claim/payment the insurance sent to the Clinic to make sure what the clinic is saying is accurate.

C) Contact your insurance and tell them that an Agent said to you on such and such a date that you would only have a $50 co-pay for the visit and why is it now $100?

It could be a mistake, it could be that the Urgent Care Clinic categorizes itself as a hospital when it files a claim and the insurance's payment computer then processes the claim accordingly and you then are responsible for $100 instead of $50.

Could it be that what they are describing as a co-pay is a mixture of co-pay and unmet deductible?

Anyway, talk to your insurance if you can prove or convince them they made the mistake they will reprocess the claim and pay the Clinic the $50 they are looking for.

I wouldn't pay until I was completely satisfied as to why you have to pay the extra $50.

If it turns out that the insurance's payment only specified that that you owe $50. If the Clinic is under contract with the insurance company they cannot ask for more than the contracted rate. It could be they didn't like what the insurance is paying and are trying to stiff you for an extra $50.

The key is:

Get a copy of the payment details that the insurance company paid on your behalf to the Clinic.

If the co-pay on that document is listed as $100, then find out why in detail it is $100 instead of the $50 you were told. Then if satisfied pay the other $50, if unsatisfied; then argue with them about it and see if they will pay. If you are in reasonably good health you may threaten to take your business elsewhere.

Question: Did the agent you originally contact know that the visit was going to be out of state, and did the co-pay rates on the card and what she quoted were they for and in-state and out-of-state?

Again find your benefit information.