DC Psychiatrist Falsely Represented That He Is Cash-Only OON

[Anonymous]

Anonymous wrote:

Anonymous wrote:Sorry, that seems frustrating by the insurance company if they are processing some as in network, and some as out of network.
It’s still only mid-April, so it may be taking some time for the doctor to be fully set up under the insurance with his own practice if he just started in January. For the first 11 visits, insurance reimbursed you 70% each—so roughly $175 per visit. The last three were processed as in-network, which means you’re only responsible for the coinsurance instead of the full $250. It might be best to contact the office billing department to reconcile the account and request a credit for any overpayment. Also maybe request the insurance company to reprocess the first 11 claims as in network.

OP said It was 70% of the allowed amount, which is probably much lower

The main issue is actually the deductible. There is no in-network deductible for office visits, but I have a $1,300 deductible for OON care, which I hit in 7 visits with this psychiatrist. That is around $1,200 plus the $700ish they messed up on for the last three claims. Smallest amount is the $75 vs. $20 copay for the four covered visits that were processed as OON.

[Anonymous]

Georgetown and Mary’s Center have some of the best perinatal mental health services in DC.

I agree on itemizing costs. I would try to verify the date doc was in network by getting that info from insurance provider. Then tally up exactly what you would have paid if they started billing in network on that date, exactly what you actually paid, and identify the difference. Put that in a letter along with how you would like to be repaid or offset future payment.

[Anonymous]

If you can get your PCP to continue your prescriptions and you only want therapy, Betsy Mencher has fertility/perinatal experience. I personally didn't click with her, but she was recommended by Shady Grove.

[Anonymous]

Terminate with him.

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:Tell him you're sure both of you want to make this right. Then figure out how much you're owed, and let him know you'll take that as a credit to count against future sessions.

Be calm and matter of fact. Emphasize the importance of honesty in a therapeutic relationship. If he cooperates, he might be a keeper. If not, you've had time to find a new doctor.
-Psychologist

I would not trust a mental health professional that uses deceit in this way, I would terminate the relationship as soon as I found a replacement (only because I know it’s very difficult to find a psychiatrist if it was a specialty, that was easy to come by they would be fired and reported right away)

I plan to terminate, but it’s going to take some time to find someone with fertility/perinatal expertise.

Postpartum Support International has a clinician directory.

[Anonymous]

If he was paid twice for the last 3 visits —first by you and then by the insurance company—he is committing billing fraud.

[Anonymous]

Anonymous wrote:OP here. The odd thing, especially, is that I now know from the in-network EOB that the negotiated rate is $228. So my doctor was engaged in all these shenanigans for an extra $22 per visit. I assumed the in network reimbursement had to have been much lower.

Clinician here. Reimbursements are sad, insulting and not a livable wage. I am out of network for this reason. I don’t know why someone who is in network would say they aren’t. Is it possible that they don’t know they are in network? Might they have been credentialed with their previous employer without their knowledge? Stranger things have happened. I would communicate my concerns with a provider before reporting them to the board. I would hope that your relationship would warrant doing so.

[Anonymous]

Anonymous wrote:

Anonymous wrote:OP here. The odd thing, especially, is that I now know from the in-network EOB that the negotiated rate is $228. So my doctor was engaged in all these shenanigans for an extra $22 per visit. I assumed the in network reimbursement had to have been much lower.

Clinician here. Reimbursements are sad, insulting and not a livable wage. I am out of network for this reason. I don’t know why someone who is in network would say they aren’t. Is it possible that they don’t know they are in network? Might they have been credentialed with their previous employer without their knowledge? Stranger things have happened. I would communicate my concerns with a provider before reporting them to the board. I would hope that your relationship would warrant doing so.

I assumed it was a mistake. I contacted the provider and asked if there was any chance he was in-network with my insurer. He said that he is and that if I'd like to go in-network moving forward that we can. I know he's not oblivious to my insurance situation because he literally had a phone call with my insurance company early on about what information he needed to include in his super bill because the first claim got denied twice for inadequate information.

The comment you're responding to demonstrates that the reimbursement in this case is less than 10% off his cash rate ($228 per 30 minute telehealth visit). I'm surprised anyone would risk it for a less than 10% benefit.

[Anonymous]

Anonymous wrote:

Anonymous wrote:Tell him you're sure both of you want to make this right. Then figure out how much you're owed, and let him know you'll take that as a credit to count against future sessions.

Be calm and matter of fact. Emphasize the importance of honesty in a therapeutic relationship. If he cooperates, he might be a keeper. If not, you've had time to find a new doctor.
-Psychologist

I would not trust a mental health professional that uses deceit in this way, I would terminate the relationship as soon as I found a replacement (only because I know it’s very difficult to find a psychiatrist if it was a specialty, that was easy to come by they would be fired and reported right away)

you all are nuts. he wasn't trying to be deceitful, seems like there are set up issues. i am the first one to complain about medical care in the US but this isn't it. talk to him, OP, and work it out

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:Tell him you're sure both of you want to make this right. Then figure out how much you're owed, and let him know you'll take that as a credit to count against future sessions.

Be calm and matter of fact. Emphasize the importance of honesty in a therapeutic relationship. If he cooperates, he might be a keeper. If not, you've had time to find a new doctor.
-Psychologist

I would not trust a mental health professional that uses deceit in this way, I would terminate the relationship as soon as I found a replacement (only because I know it’s very difficult to find a psychiatrist if it was a specialty, that was easy to come by they would be fired and reported right away)

you all are nuts. he wasn't trying to be deceitful, seems like there are set up issues. i am the first one to complain about medical care in the US but this isn't it. talk to him, OP, and work it out

“ He said in writing that while he was "trying to start a cash-only practice, it isn't exactly working out." He has been in-network with my insurance since I began seeing him in January and just lied to me.”

[Anonymous]

I am a psychiatrist and this is a confusing story. Maybe he didn’t know he wasn’t allowed to charge people for being out of network when he has a contract with their insurance? Not making excuses for him, but they don’t teach us that stuff (or anything about running a business, really) in residency. Insurance is just as opaque for clinicians as it is for patients.

[Anonymous]

I am a psychiatrist. I dont know about your doc but many of us are INN at some positions but then do an OON private practice, the issue is that insurance has started going by doc name and not practice--so hence the confusion.

[Anonymous]

Anonymous wrote:I am a psychiatrist. I dont know about your doc but many of us are INN at some positions but then do an OON private practice, the issue is that insurance has started going by doc name and not practice--so hence the confusion.

OP here. If that were true, then why is he now telling me he’s in-network, billing insurance directly, and not requiring me to pay cash up front anymore?

[Anonymous]

Anonymous wrote:I am a psychiatrist and this is a confusing story. Maybe he didn’t know he wasn’t allowed to charge people for being out of network when he has a contract with their insurance? Not making excuses for him, but they don’t teach us that stuff (or anything about running a business, really) in residency. Insurance is just as opaque for clinicians as it is for patients.

Doesn’t the agreement you sign with the insurer explicitly say you can’t do this?