In Network provider makes me file claims myself and over charges me…. Help?

One thing I’ve learned on this subreddit that credentialed, in network providers have to accept the in network rate and can’t balance bill. I have also learned that in network providers are expected (required?) to file claims themselves.

However I have an unusual situation.

I see a therapist. He is credentialed and IN NETWORK with my insurance. But he refuses to file the claims himself. He collects $135 cash from me and then gives me a super bill.

I asked him about this and he said “I maintain my credentials with Aetna so patients can be reimbursed more but I will not file claims. And my rate is $135.”

When I get the check snd EOB back from my insurance it says he is IN NETWORK, the allowable rate is $114, and my in network copay is $5. So they reimburse me $114-5= $109.

But if he was following the rules, he would charge me $5 and get paid $109 by Aetna for a total of $114.

A therapist is a very personal relationship and he is an excellent therapist. I’m reluctant to bring this up to him because he might fire me as a client.

Can Aetna sort this out with him directly without making it look like I tattled? And make him reimburse me for the incremental charges? Probably not.

Also why would Aetna reimburse me directly (they do) if he is supposed to be submitting claims himself?


submitted by /u/highbrew62

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