Help! Claim denied with PCP because it is Telehealth
I need help on how to navigate this. I am stuck in the middle between my provider and my insurance. I suspect this will be long.
Info: My health insurance offers Telehealth coverage and states that it "Follows the plan" — I'm told that means if I am at the urgent care, urgent care co-pay $75. At the PCP, pcp co-pay $35, etc.
The insurance company admits that my plan does NOT have separate pricing for telehealth services.
My PCP is Patient First– who also offers Urgent Care services. Patient First has been my PCP for 25 years. Whenever I am seen there, it is a PCP visit- regardless of what insurance I have, etc. When establishing new insurance w/ my employer, I write Patient first as My PCP. It has NEVER been a problem.
I have United Health for insurance via my employer.
Situation:
end of November of 2023, I had a telehealth visit with Patient First for a sinus infection. Upon entering my personal info to the telehealth system, the system indicated my copay would be $35 which is my PCP copay. (The system acknowledged this is a PCP visit.) I provide a CC number for my $35 but it is not charged.
Appointment goes fine, but in a few weeks I am still not feeling better, so I go in-person on NYE and pay my $35 PCP co pay in person for follow up and get different drugs and feel immensely better.
Jan 24, I get a bill from Patient First for $75 for my telehealth appointment. I called and asked why it was not $35 as they are my PCP. I was told by Patient first that insurance is denying it is a PCP visit.
This was the beginning of NUMEROUS back-n-forth with United Health and Patient First.
Patient first's story (and documentation) remains consistent.
Patient first billed United Health as a "tele health appointment." No mention of urgent care services. Patient first is listed w/ United as my PCP. Therefore, this should be a PCP appt according to Patient First, their system, and their records.
United's story has changed throughout the several phone calls and emails.
At first, I was told that the discrepancy is b/c "Patient first" in person vs "Patient First" Telehealth have different billing addresses. PF needs to rebill under the other address. United would reach out and request that– PF rebills. United still denies the PCP claim and bill it as urgent care despite address update.
Then United said it is the name "Patient First – Doctor Smith" is in person. "Patient first – no doctor" is
telehealth. And PF needs to rebill with the doctor name. PF does so. United denies it as PCP and pays urgent care.
Then United says it is b/c "PF in person" is Federal ID # _123__ and "PF telehealth" Is federal id # _987_ and that PF needs to change its Fed ID #…. PF refuses. They use different processors for payment/billing to track lines of services, apparently. Both Fed IDs are contracted with United Health so wth is the problem, according to PF.
Finally: United states that the ultimate problem is that Fed ID 123 has "Urgent Care AND PCP" in their contract. Fed ID 987 ONLY has Urgent Care. Therefore since I did business with Telehealth, I am to be charged at the contracted rate associated with Contract 987.
The United site and The Patient first Site BOTH list PF as being in network for PCP and Telehealth. There is no differentiation between PF-in person and PF-telehealth and insurance.
I have asked PF and United Health how I, as the patient, would ever know that they have 2 Contracts with United which vary in coverage. No answer. I pointed out that the websites for United and PF both list this as in-network and ONE provider; no differentiation in coverage. United has no answer.
I have asked United why PF quoted me $35 (Pcp charge) for the visit, if they are only contracted as urgent care for Telehealth — No answer.
I have been told by United Health that if I use Patient First ever again as Telehealth, it will be billed as Urgent care.
This does not align with my plan. And it does not align with either United or PF's websites. NOR is it what PF has told me is correct. PF expected to be paid as PCP.
I am at my wits end. I am now on the hook for a difference that, according to my plan, I SHOULD NOT BE.
I engaged with my PCP for PCP related services via Telehealth– which "Follows my plan" meaning it should be a PCP copay. Which United Health Acknowledges and PF agrees.
Yet b/c there are allegedly 2 contracts (with zero visibiliy to the customer) which makes PF 2 different entities according to United, that deviates from my plan.
I have already escalated w/in United as high as anyone will allow me to. They keep telling me to get PF to rebill under the other contract. PF says they only have one billing system and there isn't a 2nd contract… and they're baffled so they cannot rebill.
WHAT DO I DO to fix this so I can use my telehealth going Forward and so I am not on the hook for this BS discrepancy.
submitted by /u/K1p1ottb
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