If my health insurance policy clearly states that I do not have to pay a co-pay for well visits, can the doctor’s office charge me?

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If my health insurance policy clearly states that I do not have to pay a co-pay for well visits, can the doctor’s office charge me?

They charged me a $40 co-pay upfront, even though I called the insurance company while I was there and verified that there wasn’t supposed to be a co-pay. I was told by a co-worker with the same exact coverage that they got him for the initial $40 co-pay and another $40 for a follow up to get his lab results. They never refunded his money and that was over 2 months ago. Aren’t they bound by the health insurance contract not to charge a co-pay? If I pay it, then it is a co-pay, regardless of whether or not I have to fight to get it back.

Asked on March 18, 2011 under General Practice, Maryland

Answers:

M.T.G., Member, New York Bar / FreeAdvice Contributing Attorney

Answered 10 years ago | Contributor

Why yes they are.  If they sign on to be a list of those participating doctors then they are bound by the rules that the health insurance company sets.  They - the doctors - enter in to a contract with the insurance company and they agree to these terms.  You need to advise the insurance company of what is going on here and file a complaint. This is a form of insurance fraud and you need to also report it to the insurance department.  I would call the doctor's office and explain that you have become aware that there has been a discrepancy in the charge and that you wish it reimbursed as soon as possible.  If they do not comply send a letter and copy the insurance department.  Good luck.


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