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Our insurance says there is no copay and no deductible for COVID tests, but the doctor charged us a $50 copay and is refusing to refund it until insurance pays them. This sounds sketchy. They also tried initially refusing insurance (they are in network!) because they didn’t “think” it was covered. We confirmed 3 times with our insurance, once in the waiting room, and the provider refused to speak with the insurance agent or let her staff speak with them. Is this illegal or some kind of insurance fraud? From California.

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    The doctor has a contract with the insurance company. After you have discussed this with the doctor or their staff, without a change, you can take this up with the insurance company. You might consider other routes such as the Better Business Bureau. Aug 16, 2021 at 12:41

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I'm not 100% positive about this, whether this is prohibited by statute or by contract. I do know that Section 1371.9 of the Health and Safety Code (CA) makes it illegal for out-of-network health care professionals to charge an enrollee (you) more than an in-network professional would charge, if the facility itself is contracted. Logically, if an out-of-network professional at a covered facility cannot overcharge, then an in-network professional at the same facility cannot either.

I suspect there is a statute out there more directly on point, I just haven't spotted it.

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