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Provider didn't tell me they were out of network, what to do?

I'm going to a physical therapist.  My physical therapist benefit, according to my benefit sheet is $25 copay, no deductible in network.  I've been going for almost 2 months now and I just looked at my insurance sheets that come in the mail.  I've only had 2 insurance sheets come in so far.  I was out of town so I didn't get to open the mail.

They're not covering anything :-(  I don't understand why.  It's hard for me to call them because their hours are weird.  But one sheet is giving me a code that is "charges exceed the reasonable and customary allowance".  I don't understand how they can do that.  They've done that before to my dental.  I thought they have to cover whatever the charges are less the copay.

Then..... this is the one that really hit me.  I'm getting codes that say "Non HSM/ No Discounts Available" and then it gives me a list of how much is covered, and then it shows a deductible amount.

I don't have any deductible for in network, which leads me to believe that this physical therapy place is out of network.  But I was referred to them by my primary doctor who only gives me prescriptions for in network (I did physical therapy once before and I had no problems).  I called them and asked if they accepted my insurance and they said yes.  They said nothing about not being in network.  On their website they say they accept my insurance too.  So I don't know what to do.  Do I call my insurance and try to work with them?  Do I call the physical therapy place and ask what's up?  What if they end up telling me "no you're actually out of network"?  I can't afford to pay what could be  $3000-4000 for almost 2 months worth of therapy 2x/week. I NEVER would have gone to them out of network. The worst part is I don't feel any better really.  And all the exercises they had me do, I could have been doing it at home or in the gym twice a week.  I feel like they lied to me just to get me in the door.

Any help/suggestions/advice is most appreciated.
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282113 tn?1388163349
Dear brightskies,

Unfortunately unless you are an HMO member, it is your own responsibility to confirm whether your providers are preferred provider with your insurance carrier or not. In this case the first thing you need to do is to ask the physical therapist if they are preferred providers for your insurance carrier. If they are you are fine & you may have received the bills in error. If they are not, you will be responsible for your deductible & the out of the network charges; in which case you will have to start negotiating with your physical therapist & ask them to either join your carrier network & accept the in-network rates or at the least extend you the discount (in which case you will still be responsible for the deductible). It will take patience & great communication skills to convince them that you are a valuable customer & can potentially give them much more business. If that strategy doesn’t work, they don’t make any exceptions & ask you for the fees in full, you should ask your doctor for a different physical therapist that is for sure in network & confirm that will your insurance carrier.

Let me know if you have any other questions.


Amir Mostafaie  
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