Copay for agency services

amother

Sun, Mar 17 2024, 10:31 pm

My daughter is getting ABA and OT services through an agency. I see the insurance bills and they are making a total mint off of her. They send me bills for $10 copay each day of service (5 days a week.) DH says to ignore them; they are making enough. I always think a copay is a strict responsibility.
What do you imas think?

amother

Hibiscus

Sun, Mar 17 2024, 10:50 pm

As a person who runs a small agency:

A) you’re stealing. When you sign up for services and they accept your insurance, it’s understood that you pay the copay.
B) legally you have to pay. Yes, that’s insurance fraud if you don’t.
C) I’m assuming they’re in nework with the insurance. The reason I make that assumption is because you don’t usually pay a $10 copay when out of network. It’s usually then subject to a deductible and coinsurance, which is totally different. Therefore, even if you think they’re making enough you have NO IDEA. The in-network rates aren’t that great. For example, for speech therapy I’ll get $68 per session. I’m paying the therapist about $40-$45 of that plus employer taxes. Then I’m paying credit card fees, insurance fees, my office manager, materials, blah blah blah (many more expenses). I’m making a few dollars AT MOST. If a client would decide I was ‘making enough’ and not pay their $10 copay, I would literally lose money.
Why do you think you have the right to make that cheshbon?

amother

Forsythia

Sun, Mar 17 2024, 11:09 pm

Agencies and doctors offices cannot waive copays. It is in their contract.
Who cares how much they are making off you? You are using their services and need to pay what is owed. It is agreed upon when you signed a contract to use them.
Otherwise it is stealing...

amother

Hibiscus

Sun, Mar 17 2024, 11:32 pm

amother Brunette wrote:

You are legally and halachically responsible to pay the copay.

If you don't want this agency making money through you, don't get services through them. What a strange concept.

I agree. Or would you tell the shoe store owner that he already made too much money on you so you're going to be shaving $10 off the price? It’s no problem - you’ll just pay less and walk out with the shoes, and what could they do to you anyway?

amother

Lightcyan

Mon, Mar 18 2024, 8:13 am

Does your insurance have a co pay?
Our insurance does not have a co-pay and I used to send my daughter to a theorists that accepted our ins but she charged me $40 for each session as a “Co-Pay” when I called my ins to inquire about this they said it is fraud from the office end to collect co-pays when they are in network. The therapist signed an agreement with that ins that she won’t be asking for additional fees and they told me she could be in trouble. I ended up telling the therapist that she is stealing from us and I pulled my daughter from that office since I didn’t like how they handled a lot of things.
My DH is seeing a therapist now and again the agency is trying to collect a co pay fee but we don’t have one so I will be calling the ins and finding out what the story is.

Sometimes these agencies do steal from innocent people and they have to be put in place.

amother

Tomato

Mon, Mar 18 2024, 8:19 am

We had an agency that didn't even send us a bill or if they did it was a smaller amount than we should have owed. I think they made enough off insurance and our copays were high enough that it wouldn't be affordable and they just waived the copays. It prob was insurance fraud, but I don't think they billed us. Any bill they sent we did pay.

amother

Blushpink

Mon, Mar 18 2024, 8:40 am

Op, I understand your husband. My daughter got aba and the amount of money they were getting paid from my insurance was obscene. I don't want to hear about office staff and cc fees, it was thousands of dollars a day for a few hours with a young hs grad girl. I kept telling her t ask for a raise. Yes, there was an aba therapist checking in once in a while.

That said, the agency actually only charged me $100 a month, which I think was also insurance fraud because I was supposed to pay 10% coinsurance. And of course I paid it. But if it's financially difficult for you, ask them. It's still worth it for them to Service you.

amother

Hibiscus

Mon, Mar 18 2024, 8:59 am

amother Lightcyan wrote:

Oh wow. Which in network insurance doesn’t have a copay? The only one I know of is Medicaid…if you have Medicaid, then their rates are so low, that while it’s true that it’s illegal to charge you an extra fee, and I would never do it, I understand the agency as they’re literally losing money on you. If it’s not Medicaid, I’m really curious where such an insurance exists.

As an aside, by telling an insurance company in an agency, even if they did something really wrong - you need to ask a Rav first. It’s likely mesirah.

amother

Hibiscus

Mon, Mar 18 2024, 9:01 am

amother Blushpink wrote:

Those are out of network rates, and yes, for ABA the out of network rates are obscene. If OP has a $10 copay she is likely in network and the rates aren’t high at all.

You cannot compare.

amother

Burntblack

Mon, Mar 18 2024, 9:05 am

My son was getting aba therapy and I got the bill from insurance company the aba agency was getting 28,000 for my son!!! My husband spoke to the owner and said we pay 400 a month for insurance premiums can you waive $10 copay a day. He agreed. He said they need to send us bills for copays but to ignore them. He was getting 28,000 he didn’t need my $40 a week!!

amother

Mon, Mar 18 2024, 10:00 am

amother Blushpink wrote:

Yes, the numbers are astronomical! Every week a new claim pops up for thousands of dollars!

amother

Mon, Mar 18 2024, 10:01 am

amother Burntblack wrote:

That’s exactly how my husband feels. Like they just send it from an obligation but they don’t expect us to actually pay it 🤷‍♀️

amother

Mon, Mar 18 2024, 10:01 am

amother Hibiscus wrote:

We had to switch insurance for her to qualify for Aba services. I have horizon blue cross blue sheild omnia- in network.

amother

Forsythia

Mon, Mar 18 2024, 10:10 am

Again- they are not allowed to waive copays. It is FRAUD. They will lose their contracts, you will owe the whole amount, and they can be sued plus worse.

If you are using Medicaid you cannot be charged ANY fees beyond what Medicaid allows. No facility or convenience fees etc.

Some states have banned Balance Billing. That means that the in network sites cannot charge you the difference between what they charge and what insurance pays besides what it says in the plan (coinsurance, deductible, copay). So if a therapist regularly charges $100 but insurance pays $50 with a $10 copay- you only owe $10 and they cannot charge you $40.

And who are you to say they don't need the copays? Their accountant? It is their business. You owe what you owe. You signed a contract you owe it. Sorry but not sorry Rolling Eyes