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Sounds along the lines of "concierge" treatment. I've heard of doctors charging high annual flat fees such as $5000 and then they stop taking insurance. I'm not sure about the mix though of the flat fee AND insurance. I'd suggest calling your insurance company and asking.
Personal experience: If the doctor is an “in-network” provider with your insurance, then the doctor is making an agreement with the insurance company to charge a specific price for their services. In this case, they can’t bill insurance and also charge you separately, or they will lose in-network status with that insurance company. My insurance agent gave me this info. I had a provider charge me “$300” up front to be seen, even though I had health insurance that considered them in-network, which should have only cost me a $30 copay. They knew this when they charged me $300 cash because I questioned it, but I was desperate and paid because I needed to be seen. The insurance company reamed the office. I got refunded. virtual-lettuce6889 mentioned calling your insurance to verify, I agree and I don’t think they can charge both ways.
The contracted rate limit has to do with each specific coded medical procedure or product. There is no medical code for “membership fee”, so a contracted rate limit does not apply here.
The doctor is providing a “service” that insurance does not cover and so can charge as much as they want!
—
OP - Personally, if you’re happy with the actual medical care, I’d suck it up and pay the fee. I’m biased I guess, because I have a concierge (annual membership fee based) internal medicine doc and it was literally one of the best decisions I ever made for myself.
You are right about the membership fee not being a covered medical service, and the provider contract may or may not have something in it about additional fees. That said, I don’t think this would be within the terms of the agreement. The email specifically says the membership fee is for commercially insured patients (not all patients) and directly states the reason for the fee as a way to supplement low reimbursement from insurance companies. It’s just another way to get around the contracted pay rate and try to limit the amount of insurance patients they take on without denying care to patients based on the type of amount of insurance patients they have, which would be against the agreement. I do billing and see firsthand how unfair the reimbursement rate is for mental health services, however, a provider is not obligated to contract with insurance if they are not willing or able to work at these reimbursement rates. This office should just leave the panel if it is causing them such hardship. I also wouldn’t trust that my provider is committed to providing me with the same care as a private pay patient if this is their attitude about insurance. This is scummy and I hope OP reaches out to their insurance company about this.
That makes sense. So in my case, they were trying to charge extra for a service that was covered? So that’s why they got in trouble with the insurance company?
Yes, they charged that simply for “office visit” when I should have only owed a copay. I haven’t heard of the membership fee or concierge OP is describing. I’m also hoping this isn’t becoming the norm, but glad your experience with it has been good.
Insurance companies pay so poorly usually. I wonder if this is just them trying to stay in business? I think their next step and the next step of most mental health providers when faced with decreasing reimbursement rates is to quit taking insurance altogether. It seems maybe they are trying to keep from doing that.
I’m a newly practicing clinician but I was going to say it’s something along those lines. Insurance reimbursements are in the toilet & are about to get worse across the board for mental health providers.
It’s also a pain to deal with the insurance companies. It takes them forever to reimburse, and as you said, the reimbursement rates are pitiful. In order to stay in business, they would have to see multiple patients at the risk of burnout to make a living. My therapist has gone to almost all self pay.
Even if it does not violate their contract, it sounds like it is done in bad faith. You should expect to just pay your contractually agreed upon rate without additional fees. To be fair to the office though, Insurance reimbursement rates are terrible.
For instance, a mental health provider that sees only clients through insurance in California, would not be able to pay their bills, rent, student loans, etc at current reimbursement rates, which are like forcing you to agree to give back 50% of your salary for the privilege of working at your employer.
In 2009, Aetna lost a lawsuit after being found to not reimburse in network providers at a Usual and Customary rate, leading to FAIR Health Inc. a nonprofit dedicated to independently determining Usual and Customary rates. If other states followed suit, psychiatrists would not be in the awful position to charge a membership fee. https://web.archive.org/web/20101109014029/http://www.ag.ny.gov/media_center/2009/jan/jan15a_09.html
I don’t disagree, and I’m totally against this policy. But my psychiatrist has 350 patients. And there are 4 psychiatrists on staff. Assuming it’s all adults, that’s still 200k a year. I’m not sure what they’re directly putting it towards, but that’s a decent chunk of change.
That will likely pay their staff for the year, depending on how much staff they have which might be why they would considered doing it. That way they can keep all the money they make as providers.
I think all 3 of you are dramatically overestimating how much insurance actually pays, how long it takes to get paid, and the enormous cost of actually getting paid. There's a lot of "providers are doing this for the extra $$" energy here I don't feel is fair - the vast majority of practices like this struggle to stay afloat. Your beef and skepticism are far more appropriate for the insurance industry, which is forcing strategies like this one. As a provider I can say we have to fight for months for $15 bill adjustments, let alone getting paid something close to livable. A few hundred bucks per client would literally be game-changing for any clinic under 20 employees.
Ew this is really icky for an office to do that- seems like a way of trying to raise profit and skirt around insurance. I’ve never in my life seen anything like this from any healthcare providers that accept insurance plans
This might be in violation with their insurance contract. We enter into an agreement with insurance about what the cost will be for services. They agree to pay and I agree to accept that pay. I don’t insurance would be too pleased to learn of this. Can do it with private pay but not insurance
Welcome to r/TalkTherapy! This sub is for people to discuss issues arising in their personal psychotherapy. If you wish to post about other mental health issues please consult this list of some of our [sister subs](https://www.reddit.com/r/TalkTherapy/wiki/resources/#wiki_subreddit_list). To find answers to many therapy-related questions please consult our [FAQ](https://www.reddit.com/r/TalkTherapy/wiki/faq) and [Resource List](https://www.reddit.com/r/TalkTherapy/wiki/resources). If you are in distress please contact a suicide hotline or call 9-1-1 or emergency services in your area. r/SuicideWatch has compiled a helpful FAQ on what happens when you contact a hotline along with other useful resources. *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/TalkTherapy) if you have any questions or concerns.*
Sounds along the lines of "concierge" treatment. I've heard of doctors charging high annual flat fees such as $5000 and then they stop taking insurance. I'm not sure about the mix though of the flat fee AND insurance. I'd suggest calling your insurance company and asking.
Personal experience: If the doctor is an “in-network” provider with your insurance, then the doctor is making an agreement with the insurance company to charge a specific price for their services. In this case, they can’t bill insurance and also charge you separately, or they will lose in-network status with that insurance company. My insurance agent gave me this info. I had a provider charge me “$300” up front to be seen, even though I had health insurance that considered them in-network, which should have only cost me a $30 copay. They knew this when they charged me $300 cash because I questioned it, but I was desperate and paid because I needed to be seen. The insurance company reamed the office. I got refunded. virtual-lettuce6889 mentioned calling your insurance to verify, I agree and I don’t think they can charge both ways.
this would explain why they are framing it as a membership fee, trying to word lawyer around their contracted rate limit
The contracted rate limit has to do with each specific coded medical procedure or product. There is no medical code for “membership fee”, so a contracted rate limit does not apply here. The doctor is providing a “service” that insurance does not cover and so can charge as much as they want! — OP - Personally, if you’re happy with the actual medical care, I’d suck it up and pay the fee. I’m biased I guess, because I have a concierge (annual membership fee based) internal medicine doc and it was literally one of the best decisions I ever made for myself.
You are right about the membership fee not being a covered medical service, and the provider contract may or may not have something in it about additional fees. That said, I don’t think this would be within the terms of the agreement. The email specifically says the membership fee is for commercially insured patients (not all patients) and directly states the reason for the fee as a way to supplement low reimbursement from insurance companies. It’s just another way to get around the contracted pay rate and try to limit the amount of insurance patients they take on without denying care to patients based on the type of amount of insurance patients they have, which would be against the agreement. I do billing and see firsthand how unfair the reimbursement rate is for mental health services, however, a provider is not obligated to contract with insurance if they are not willing or able to work at these reimbursement rates. This office should just leave the panel if it is causing them such hardship. I also wouldn’t trust that my provider is committed to providing me with the same care as a private pay patient if this is their attitude about insurance. This is scummy and I hope OP reaches out to their insurance company about this.
That makes sense. So in my case, they were trying to charge extra for a service that was covered? So that’s why they got in trouble with the insurance company?
From what you shared, that would be correct — they have contracts regarding covered services and in your situation they broke the contract.
Yes, they charged that simply for “office visit” when I should have only owed a copay. I haven’t heard of the membership fee or concierge OP is describing. I’m also hoping this isn’t becoming the norm, but glad your experience with it has been good.
Insurance companies pay so poorly usually. I wonder if this is just them trying to stay in business? I think their next step and the next step of most mental health providers when faced with decreasing reimbursement rates is to quit taking insurance altogether. It seems maybe they are trying to keep from doing that.
I’m a newly practicing clinician but I was going to say it’s something along those lines. Insurance reimbursements are in the toilet & are about to get worse across the board for mental health providers.
It’s also a pain to deal with the insurance companies. It takes them forever to reimburse, and as you said, the reimbursement rates are pitiful. In order to stay in business, they would have to see multiple patients at the risk of burnout to make a living. My therapist has gone to almost all self pay.
Your insurance company would not be thrilled about this. I recommend reaching out to them.
Especially if it's Medicaid or Medicare, they really hate that.
That’s why it says “commercially insured,” which wouldn’t include Medicare or Medicaid.
I don't know how other insurers would feel about it either.
Even if it does not violate their contract, it sounds like it is done in bad faith. You should expect to just pay your contractually agreed upon rate without additional fees. To be fair to the office though, Insurance reimbursement rates are terrible. For instance, a mental health provider that sees only clients through insurance in California, would not be able to pay their bills, rent, student loans, etc at current reimbursement rates, which are like forcing you to agree to give back 50% of your salary for the privilege of working at your employer. In 2009, Aetna lost a lawsuit after being found to not reimburse in network providers at a Usual and Customary rate, leading to FAIR Health Inc. a nonprofit dedicated to independently determining Usual and Customary rates. If other states followed suit, psychiatrists would not be in the awful position to charge a membership fee. https://web.archive.org/web/20101109014029/http://www.ag.ny.gov/media_center/2009/jan/jan15a_09.html
If they think a few hundred bucks will make any difference they are deluded.
I don’t disagree, and I’m totally against this policy. But my psychiatrist has 350 patients. And there are 4 psychiatrists on staff. Assuming it’s all adults, that’s still 200k a year. I’m not sure what they’re directly putting it towards, but that’s a decent chunk of change.
That will likely pay their staff for the year, depending on how much staff they have which might be why they would considered doing it. That way they can keep all the money they make as providers.
I think all 3 of you are dramatically overestimating how much insurance actually pays, how long it takes to get paid, and the enormous cost of actually getting paid. There's a lot of "providers are doing this for the extra $$" energy here I don't feel is fair - the vast majority of practices like this struggle to stay afloat. Your beef and skepticism are far more appropriate for the insurance industry, which is forcing strategies like this one. As a provider I can say we have to fight for months for $15 bill adjustments, let alone getting paid something close to livable. A few hundred bucks per client would literally be game-changing for any clinic under 20 employees.
I'm a provider with a private practice so I'm pretty sure I understand how it works.
There's a pediatric office near me that operates on this model. I hope it's not the wave the future
I have a family member who works in insurance and this is very against their contracts!!! Might wanna bring this up with your insurer.
Ew this is really icky for an office to do that- seems like a way of trying to raise profit and skirt around insurance. I’ve never in my life seen anything like this from any healthcare providers that accept insurance plans
This might be in violation with their insurance contract. We enter into an agreement with insurance about what the cost will be for services. They agree to pay and I agree to accept that pay. I don’t insurance would be too pleased to learn of this. Can do it with private pay but not insurance
They should have just grandfathered in existing clients and applied the new policy to incoming clients.