Being charged over $500 for an "experimental" test

Last year I sought out an evaluation for autism & ADHD. I found an autism specialist in my area who said she did evaluations. She’s an in-network provider with my insurance. I asked her how it works and she said:

“The complete diagnostic evaluation for ASD will require 4 two-hour sessions on different days, so the insurance will cover some of the evaluation, and about 6-7 office hours to process the assessments and write the complete evaluation, which will have to also be on different days due to insurance rules. Adding the ADHD evaluation would add one more 2-hour session.”

At the time she worked at a counseling center. On our first session, she let me know that she would be leaving the center soon and starting her own private practice and asked if I was okay with that — I agreed. She told me upfront that insurance companies often don’t over the cost of adult ASD assessments, and that insurance would cover more by the appointments being spread out as one-hour sessions. In ASD spaces online it’s often talked about how it’s unfortunate that insurance plans tend to only cover ASD evaluations for children, so I was under the impression she was doing this because she wanted to make the process less expensive for adult clients. This was a little confusing though because in the prior exchange she said it was because of insurance rules. She said the the evaluation is 12 sessions and costs $80-$100 per session, and the the evaluation costs $1,500 total, but it would be about $500 after insurance. So my understanding was that by paying individually for these sessions each week, it would culminate to the total price and by the end of the 12 sessions it would be paid for entirely. My copay for each session was $30. Note that there was never any written documentation stating the costs of her services, I never signed anything agreeing that I would pay X amount, etc.

It took her 7 months to deliver the diagnostic report which was a problem within itself. When it was almost ready, she said the remaining balance that insurance didn’t cover was $475.39 and it would get charged to my card at time of delivery. I thought I had already paid for the evaluation when I’d paid for the individual sessions months ago, so I wasn’t sure if there’d been some misunderstanding. She also used CPT codes for “Psychotherapy (60 minutes)” for the evaluation sessions when billing insurance. I went to the internet for advice and several people told me that it sounds like she could be committing insurance fraud, that this isn’t how psych evaluations work, and she may not even be credentialed to have done this evaluation in the first place. Also after each session I was charged automatically, which I’m now finding out were technically unauthorized payments because I didn’t sign a card authorization form. I was informed to cancel my card before the payment went through. I only turned my card off temporarily thinking it would block the charge but it still went through. I waited to see if she would file this with insurance but she didn’t.

I texted her asking her if she could send me an itemized bill for the $475.39 charge and she sent me the generic autogenerated invoice from the therapy portal generates after each session. I asked her more specifically to send me versions of those bills with the amount billed to insurance and patient responsibility, and she said I would have to look at each of the 16 bills for each of the individual sessions or the “email I sent detailing all of this information”. There weren’t 16 sessions bills, so it was another inconsistent number. She also didn’t send an email detailing any of this. I said I didn’t see that info on file and asked if she could send a copy of the claims for those dates that were submitted to insurance, and it almost seemed like she was trying to guilt-trip me. She said she could do it by the end of the day but it would “take a considerable amount of time to go back into the records and resend all of that information to you.” I told her I only needed the info for those two dates, and she finally said “there were no claims filed for those dates because insurance does not cover autism evaluations for adults.”

I called my insurance company to check behind her and they said my plan does cover ASD & ADHD evaluations. I was giving them more details and they confirmed what everyone’s been telling me — that the way she stretched the psych evals isn’t how it’s supposed to work at all. That it’s usually a one-time thing that lasts a few hours and the $30 apiece wasn’t normal. It also perplexed them that she was a therapist doing psych evaluations, and it only would’ve been only $30 (total) if done normally by a psychologist. They said that’s probably why the claims weren’t submitted. Then because my phone’s having issues my call dropped in the middle of the conversation, and the office was closed for the weekend after that. Since I can’t call them back until Monday, it was sort of a cliffhanger so I’m wondering what might happen next in this kind of situation so I can just be aware and mentally prepare myself. Would I potentially get my money back for those sessions (my top concern)? Is there a chance I could end up getting billed more by insurance for accidentally going to someone unqualified, or would full penalty be on her? Would this turn into something legal? Could this be something that ends up putting her in jail? Etc. Etc. It doesn’t have to be answers to all of those questions but those are the kinds of things I’m wondering about.