This is a story of why you should always check all the details of your particular insurance plan, even if you think you know them all. For your doctor may not tell you if you are overpaying, even if they’re making a profit from it. Or maybe especially if they’re making a profit from it…
My insurance card says on it “$20 co-pay office visits”. That’s all, in regards to office visits. Nothing more, nothing less. When we first got this insurance plan, I did read through the contract and terms, but I was childless and I think I kind of glossed over things relating to kids. When we had our first child, I started taking him to a pediatrician, and we paid $20 copays for all his visits, well-child and sick visits. I never thought twice about it, and the receptionist at the office happily took our money every time. I never let any kind of balance accrue, so I never got a bill of any kind, so I never really knew what the insurance company paid. The doctor’s office was happy, so I assumed they were paying the rest (which they were, but there’s more).
We became increasingly dissatisfied with our pediatrician’s office for other unrelated reasons over the course of the next two years, and soon after my daughter was born, we decided to look for a new pediatrician in the area we were moving to (which was only ~20 minutes away from the current pediatrician but since we were unhappy, we decided to make a change at that time). Concurrent with that, our insurance company started sending out explanation of benefits sheets for office visits in addition to the ones they sent out for everything else, and I noticed that my office visits ones, for a well child visit they said my portion was $0, whereas the sick child visits they said my portion was $20. I assumed that for some reason the copay wasn’t shown on the well-child visits and didn’t think much more about it.
We switched to the new office, and had our first well child visit, which I paid a $20 copay for. However, the next time I came in for a well-child visit, an interesting thing happened. The office told me that my insurance had responded to their billing letting them know that they do not charge a copay for well-child visits. So I got a $20 refund from the office for my last visit. I honestly was astounded. Was this a new thing? I called my insurance company, and no, all along I had no co-pay for well-child office visits. And in almost three years of well-child visits with my son at the other pediatrician’s office, no one had ever told me that they were being paid by the insurance company for my copay as well as by me. If you don’t have kids, let me tell you, you have a lot of well-child visits in the first two years. Nine or ten of them, actually. After that they taper off to once a year, but I had had ten well-child visits with my son and four with my daughter before we switched to the new office. $280 of copays we shouldn’t have paid.
I called the old pediatrician and basically, they claimed ignorance. They did say once I hounded them enough that they could see for my most recent visits with my daughter, they were compensated for my copay, so they did eventually refund $60 of my payments. But they claimed they had no record of anything before that in regards to my copays and what the insurance paid, and they could not go back any further (basically they refunded the ones paid in the same calendar year as I was calling in). Honestly, one of our issues with that office that made us switch was their utter lack of organization, so I can believe they have no clue. And I am certain they would have never told me that their records showed they owed me even $60. Ever.
My insurance plan is a pretty popular one in my area, so I wonder how many more people are paying doctors copays that they have no need of paying? Make sure you check all the details of your insurance plan – you are your best (and only, sometimes) advocate.
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