Is this potential insurance fraud?

[MarionC]

I just got a copy of a bill from my doctor to my insurance company.
I went for my annual bone density scan and also got an injection. I spent less than five minutes with my doctor and less than 15 minutes total in the office.
The bill was for $2,733.00
The visit was $260, getting the injection was $60 and the scan was $254.
The rest, $2159, was labeled « misc. office services ».
The doctor received $1149.00
Does anyone understand how all this works?

 

[marcy]

Holy cow! That doesn't seem right. I have no idea how it works. Maybe call the doctor's office and ask is included in that fee?

 

[ksinger]

Being a rather...plush, user of healthcare, I'm dealing with a similar situation, although not nearly as egregious. Holy cow indeed. I would call it less an attempt at insurance fraud, than an attempt at end of year accounting sleight of hand.

The doctor - or the facility (and this is important - doctor and "facility" can bill separately) can bill for just about anything they can dream up. Getting insurance to pay for it? A tad harder. Or you to pay for it? Again, harder.

Understand, there is still the chance that it will just disappear. So no need to truly fret just yet.

But being one to like to take care of business and get a jump on things, my advice to you at this point is get your phone out, dig your heels in, and put on your best New Age serenity music. Be sure to have some Death Metal in the queue just in case you need it. And start calling.

First, call your insurance (who is probably laughing crazily at this doc's attempts) and tell them what happened in the office on that date of service. Ask them if they are seriously considering paying that bill because you received no extra services and assure them (multiple phone calls to more than one person on more than one day are good) that nothing other than those things you noted, were done, and no other people were involved but you or the doc and maybe the nurse.

Next, call the doctor's office billing service, and ask for an ITEMIZED BILL. They DO NOT like this. They will likely give you as much runaround as possible. Don't give in. Make THEM prove to YOU exactly what extra services, or used rubber gloves and exam table paper, justify that 2000 dollar bill. Itemized. Keep bugging them until you get it. Make them understand that you are contesting this bill and will not pay until they prove to you what cost 2000, and insurance says you owe a PORTION of that. Let them know that you've already contacted insurance about this. FEET TO THE FIRE.

Rinse, wring, repeat.

Here's the deal. You insurance contracts with the doctor (or entity, say, a medical group) to allow certain charges. You are paying premiums to ensure that you get the benefit of those contracts - lowered bills, etc. If the doc is in network, and the insurance will not allow the charge, most generally (I'm sure there are some weird deals out there) you are not responsible for it either. For example, that's how they charge $5000 for an MRI, insurance allows $1000, and your contract's 80/20 split means you are responsible for $200.

It's my opinion, hearing how many people are being hit with similar situations right now, that medical entities are trying desperately to throw as many of these as they can before year end, just to see how many stick.

FIGHT IT. Go on the offensive.

 

[AprilBaby]

How outrageous! I would ask the ins company to explain what they paid for.

 

[ksinger]

How outrageous! I would ask the ins company to explain what they paid for.

I've never seen the actual bills sent by the doc to the insurance company. There is no reason for the patient to see that, and it's done electronically anyway. Jimmianne will correct me, but I suspect the reason she has a copy of what the doctor billed the insurance company - as opposed to what his office would bill her for - is because the insurance company sent her a courtesy copy of their denial of the charge, and request for further information from the doc if he would like to pursue it further. So I bet insurance hasn't paid a dime yet.

Insurance companies are indeed part of the Matrix of Medical Evil, but they are generally not so easily duped and eager to pay out large sums like that without justification. Two grand for "miscellaneous office services" is pretty ballsy and assumes the insurance companies are just writing checks without looking. My similar charge was only $151 dollars and someone was damn sure looking at it and denied it. You can bet someone is looking even harder at $2000.

 

[MarionC]

To clarify, every time I go to a health provider I get a statement from Blue Cross showing what was billed and what was paid, and how much Blue Cross paid vs. how much was paid by medicare.
My reason for being hesitant has been once I expose the doctor, I might not be welcome there and will have to find another one. But maybe that’s not a bad thing!
I think it might be best to call the doctor’s billing department and ask them to explain the huge charge.
I can see why patients might just ignore the facts. I pay nothing out of pocket, so it doesn’t affect me directly, but it is wrong.
My other doctor charges $200 for a 15 minute office visit and gets paid $100. That one I just ignore.
This recent bill from the bone doctor though was outrageous.

 

[ksinger]

OK. They paid it? Hat's off to your doc's medical coding then. Wow.

Curious how much they allowed for the bill then. Surely not $2000?

And if you're dealing with Medicare, I may need to pick your brain at some point. It's in my not-to-distant future....

 

[JDDN]

That seems really weird. I would definitely start by calling your doctor's office and ask for the office manager. Ask him/her what specifically the "misc. office services" were that were billed to insurance. If you want to get technical, ask for CPT codes and relay them here (if it's not to personal of course!) and I can tell you what they are. I hate this part of health care SO much. It's one reason I tolerate Kaiser which I have a love hate relationship with.

 

[ksinger]

That seems really weird. I would definitely start by calling your doctor's office and ask for the office manager. Ask him/her what specifically the "misc. office services" were that were billed to insurance. If you want to get technical, ask for CPT codes and relay them here (if it's not to personal of course!) and I can tell you what they are. I hate this part of health care SO much. It's one reason I tolerate Kaiser which I have a love hate relationship with.

....aaaaand they'll hem and haw and hem and haw.

Yeah, my responses tell you tell I'm deep in my own medical hell right at the moment.

I spent an entire HOUR on the phone with someone from BCBS last week. I'd tell you guys about it, but you'd die of old age, and I've made so many phone calls, looked at so many bills from so many entities (for the same amount) that I can hardly keep track of it all myself.

 

[YadaYadaYada]

Maybe it's ignorance on my part but I never realized that every little thing they do at a visit is another dollar in their pocket.

For example I went to a neurologist and took some test on an IPad to evaluate cognitive function, that test, 10 minutes in total was $275 and was not covered by insurance because they don't cover the test if given electronically. Mind you it could have been done on paper but this being the new age and all.....

I would request an itemized breakdown of what exactly is included in "misc office expenses." Even if Insurance has already paid you have a right to know exactly what the bill included.

 

[ksinger]

Maybe it's ignorance on my part but I never realized that every little thing they do at a visit is another dollar in their pocket.

For example I went to a neurologist and took some test on an IPad to evaluate cognitive function, that test, 10 minutes in total was $275 and was not covered by insurance because they don't cover the test if given electronically. Mind you it could have been done on paper but this being the new age and all.....

I would request an itemized breakdown of what exactly is included in "misc office expenses." Even if Insurance has already paid you have a right to know exactly what the bill included.

The stupid! It buurrrrrrnns usssss!

 

[YadaYadaYada]

The stupid! It buurrrrrrnns usssss!

Well I negotiated and got the amount I had to pay down to $35. However I had to nag them constantly to get anywhere, this is why I avoid any doctors at all costs if I can help it!

 

[JDDN]

....aaaaand they'll hem and haw and hem and haw.

Yeah, my responses tell you tell I'm deep in my own medical hell right at the moment.

I spent an entire HOUR on the phone with someone from BCBS last week. I'd tell you guys about it, but you'd die of old age, and I've made so many phone calls, looked at so many bills from so many entities (for the same amount) that I can hardly keep track of it all myself.

Oh. I know. When I had a PPO I would spend hours on the phone parsing out details that were mind numbing. It's enough to drive one mad. And this is why I have a love hate relationship with Kaiser. There's zero paperwork, zero EOB's, etc. But try and get certain services and forget it. I guess you win some and lose some. Needless to say it's all very frustrating!

 

[Bron357]

That is totally outrageous. No wonder the US medical system is a shambles. Here in Australia, if you were a visitor from overseas, ie not covered by our free medical care, a short, basic doctors visit is less than $85. A shot betwen $20 and $80 (depending on what it is) and a bone scan around $300. That’s it, even as a visitor.

 

[whitewave]

That is totally outrageous. No wonder the US medical system is a shambles. Here in Australia, if you were a visitor from overseas, ie not covered by our free medical care, a short, basic doctors visit is less than $85. A shot betwen $20 and $80 (depending on what it is) and a bone scan around $300. That’s it, even as a visitor.

It is more complicated here, as you know. Doctors can't give cheaper/discount prices for cash visits (assuming your scenario of out of the country/no insurance) because that is also considered fraud-- has to do with the insurance companies.

Yes, it is quite a mess.

 

[Bron357]

Here with bulk billing doctors you just hand over your Medicare card and sign. If you don’t have a Medicare card they just charge the normal rate, which is only about $85 for a local general doctor. Of course, specialist doctors charge a much bigger consultation fee, again free if they bulk bill or we sometimes have “out of pocket” expense,maybe $50. Anything done in public hospitals is free, even neurosurgeons!, but private practice does exist and that’s when you might have out of pocket because you’re choosing a particular specialist at a time you chose and not just whoever in on that shift at the hospital after you’ve waited a few hours (unless emergency case).

 

[redwood66]

@ksinger and @JDDN are right. You should definitely ask for the itemized billing and keep asking if they hem and haw. I asked for one for my overnight stay in the hospital and it was about 10 pages of every little thing used or done. You don't see those things on your insurance's EOB. Medical coding is mind boggling to me and mistakes are made (hopefully accidentally) so you have to be vigilant.

 

[smitcompton]

Hi,

These are not mistakes. Medicare is contracted and medical personnel know that they will not get paid for some of what they put down. The doctor got 1100.00 for his services and he was not surprised that he didn't get the rest. This helps Drs et al to keep up the illusion of the usual and customary fees that medicare is discounting. There have been times that I used to question nursing visits to my home. They came for years. After looking at the charges and calling the nursing service they explained they didn't actually get paid what they asked, and sure enough several months down the road the amounts they were paid were subtracted from the new bill. I don't believe this is fraud. They know they wont get paid for it, but for statistical purposes they want the insurance co to know they are getting a discount.

I just spent 5 weeks in hospital and convalescent home where charges were made for 2 drs, one that I never saw, another that I saw maybe once a week. The second Dr. charged medicare almost every day.

Now, the hospital Drs were a different story. The first one spent a lot of time with me inquiring if I had powers of attorney ect.ect. I was worried that I might not make it home if he took so much time with me. I think 4 more Drs were involved and they spent a lot of time with me, and came often. I thought it was unusual. When I got the statement of services I noticed that a time element was included. The first Dr. said he spend 35 minutes which which he did. The other had 25 minutes each. Some did stay for 25 minutes and other 15 minutes but non were in a hurry. I assure you I am not that charming. So, this is something new where Drs are expected to spend time with the patient instead of a 5 minute visit.

I think you should ask what those other charges are for, but don't think of it as fraud. They just might tell you, but sometimes the clerks don't know the answer.

Annette