Question
I called around for a psychiatrist who took my ins which is SAG Blue Cross. This doctor said that he took it, so I make an appointment. On the first appointment i told him i was really worried about the cost because i was in school, starting a new business and unemployed and i was scared the bills would start adding up. He said "Don't worry, I'll take care of you." I went to him 7 times over a month and a half period and when i when i got the EOB's, they said they didn't cover any of it! So i called SAG as asked why this was. They said i needed prior auth from Value Options which is like a second health ins for mental health and that i needed to go to someone on their list. I didn't understand the idea of Value Options before all of this. Well it happens that the doctor in question IS contracted with value options and on that list. He must have known that this would end up happening. If he contracted himself with value options, then he IS aware that that's the mental health provider for SAG/Blue Cross. SO why would he then bill SAG/blue cross if he knows they don't pay for mental health? Why would he tell me he took my insurance without asking me if i got a prior authorization and/or calling SAG to verify like all the other doctors I've gone to do? Why would he say "Don't worry I'll take care of you" and then proceed to charge me the maximum dollar amount each time i saw him no matter whether i was there for 15 minutes or for 45 minutes. He's trying to collect $1925 and if i had the prior auth it would be about 300. Even less really because he lied on the appointment lengths. What do i do? Value Options says i cant reverse it now, its too late. I can send a letter to them asking for retro but they've told me it probably wont matter. This doctor lied and was dishonest and made me believe I was safe. But now its his word against mine. Hope you can give me some tips. Maybe help me with what I can say in my appeal letter to Value Options that will help win my case. There is so much more to this story but my question is already VERY lengthy, sorry for that. Cant wait for your response! Thanks!
Answer
Hi Gabe!
I think I would call the Dr and ask him about the bill. Advise him that he told you that it was taken care of and now you are getting billed. Ask him if he got authorization and if he did not ask him why he did not. Your best bet is to get the Dr to help you with the appeal.....if he takes some blame they may go back and give you a retro authorization.
You have a better shot of winning your appeal with the Dr taking the blame. So this is probably your best bet.
Since this Dr is on the Value Option list as a participating provider I would think if he takes the blame and helps you with your appeal, you may win. Don't let the Dr tell you no-----insist he helps you since it was his error.
Good Luck!
Tricia
