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So, i recently went to a doctors appointment. When scheduling my appointment i told the doctor i would only go to it IF it is covered by my insurance. I went to the appointment and gave them my insurance information (again repeating i wouldn't continue if uncovered) and they sent me back to see the doctor. Long story short i get a bill for $700 because my insurance didn't cover it. Are they allowed to do this? This is literally scamming people for money as my intentions were made very clear.

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    Doctors aren't experts on what your insurance will cover, did you confirm with your insurance that it would be covered? Did the doctor tell you that it was covered? Also, coverage doesn't necessarily mean you don't pay anything, there's a lot of variety in coverage. Was it partially covered by your insurance?
    – Hart CO
    Commented Jun 24, 2021 at 16:40
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    You repeatedly said you wouldn't see the doctor without confirmation of coverage, but you did anyway. You should have called your insurance first to find out if they would cover this particular doctor.
    – chepner
    Commented Jun 24, 2021 at 16:47
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    What's the exact reason given by the insurance company? I suspect you were covered, you simply did not meet your deductible.
    – user71659
    Commented Jun 24, 2021 at 17:57
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    When you say "my insurance didn't cover it", do you mean you insurance didn't cover the procedure? Or do you mean you insurance didn't cover the $700? It's entirely possible for your insurance to cover your procedure and you also to receive a bill for costs that weren't covered by your insurance. Commented Jun 24, 2021 at 18:23
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    In my experience doctor's offices normally check your insurance before your appointment. While this is by no means foolproof it catches most cases where the insurance does not cover. It does not catch cases where your deductible isn't met and it's liable to miss cases where your insurance changed (but you should know about those cases.) You need to look at the explanation of benefits you received from your insurance, why is coverage denied?? Commented Jun 25, 2021 at 15:09

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Yes, the providers are almost certainly allowed to do this and it's not a scam

I am not familiar with specific laws in North Carolina, so there may be other factors at play. But the major issue is this:

Doctors and other clinical staff are not experts on your insurance policy, nor do they have access to it. They do not, and usually cannot, know exactly what your insurance will and will not cover.

It's not clear from the description of events that the doctor's office actually assured you that the visit would be covered, and in my experience providers are pretty cagey about guaranteeing that sort of thing for the reason bolded above-- providers can't look at your insurance policy. If they try to bill and the claims are rejected, then you're on the hook because you did receive the services. A provider can usually tell you if they are in the provider network for a given insurer, but that's often the most reliable information they can give you.

If you want to schedule medical services only under a condition that your insurance will pay, the burden of determining who will be responsible for the bill is on you. The way that you would do this would be to contact your insurer and ask about the specific service (and provider!) you want, and they can tell you if your policy will cover it. Even this is not quite a guarantee, as the insurer cannot know how the provider will bill the service and will have very limited ability to make them bill in a certain way.

It may or may not have been an issue in this case, but it is also important to bear in mind that it is not a binary situation between "covered" and "not covered". Depending on the specifics of your policy it's possible that your insurance will cover a service but that there will still be some portion (up to 100%!) which you are responsible for paying. For example, if you have a deductible that hasn't been met you may need to pay for the entire visit out of pocket even though, had your deductible been met, the insurance may have paid the entire bill.

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    Typically, the provider has the patient sign forms that say "we bill your insurance as a courtesy" - which indeed means they are not responsible. As a practical matter, you could ask the provider, nicely, to write off your bill. E.g., "Both you and I anticipated that this would be covered by insurance, but it was not. Would it be possible to write off my bill beyond the co-payment amount?" See what they offer in response; it doesn't hurt to ask. Commented Jun 25, 2021 at 16:57

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