I think I've been unwittingly an accomplice to insurance fraud. Help.
October 13, 2015 10:21 AM Subscribe
An in-network doctor works at an out-of-network practice, and chose to bill me as out-of-network so the insurance company paid more--but she also didn't bill me anything. I feel weird. Now what?
I had an infected toenail. I looked on my insurance website, found an in-network podiatrist, and went to see her. She examined me, gave me antibiotics, and had me return in a week, when she removed my toenail. She had me return the week after the toenail was removed, to make sure everything was ok.
She charged me a co-pay for my first visit, but for the toenail removal visit, and the follow-up visit, she did not. At the follow-up visit, I asked her how much I owed for both visits (I had assumed I just didn't pay last time because I was faint and discombobulated since I'd just had my toenail ripped out, and that they were just going to charge me next time). She said I owed nothing. I was confused, and asked why, and she said not to worry about it. I pressed, and she finally explained that although she, as a doctor, was in my network, the practice was not, and that if she bills the insurance from the practice, she gets paid twice as much from the insurance company. Naively, I said "but then I have to pay thousands of dollars!" and she said "No, you don't. I'm not going to bill you at all." I said "I'd really rather you just bill me in network" and she said it was already done out of network and couldn't be changed. I didn't know what to do, so I left.
So basically, this is insurance fraud, correct?
I've already decided not to go back to this doctor (especially because I got a call a few days later that they biopsied my toenail--without asking whether to do so, or telling me they were going to do so--and pre-emptively scheduled me an appointment to come in and discuss the results: what am I, an insurance cash cow?).
However: I got in the mail today a 50 dollar check from my insurance company, and an explanation of benefits saying I owe the out of network provider 1500 and some change (which I'll never be billed for). The 50 dollar check is what they are reimbursing me. I feel very weird about this and I don't know what to do. If i don't cash the check, do i look suspicious? If I do, am I complicit in insurance fraud? Do I notify the insurance company about this (but if I do, am I going to be charged thousands of dollars by the insurance company itself, for the amount they paid the doctor over the in-network amount?) Or is this not that big of a deal and I'm over-reacting?
Please advise.
I had an infected toenail. I looked on my insurance website, found an in-network podiatrist, and went to see her. She examined me, gave me antibiotics, and had me return in a week, when she removed my toenail. She had me return the week after the toenail was removed, to make sure everything was ok.
She charged me a co-pay for my first visit, but for the toenail removal visit, and the follow-up visit, she did not. At the follow-up visit, I asked her how much I owed for both visits (I had assumed I just didn't pay last time because I was faint and discombobulated since I'd just had my toenail ripped out, and that they were just going to charge me next time). She said I owed nothing. I was confused, and asked why, and she said not to worry about it. I pressed, and she finally explained that although she, as a doctor, was in my network, the practice was not, and that if she bills the insurance from the practice, she gets paid twice as much from the insurance company. Naively, I said "but then I have to pay thousands of dollars!" and she said "No, you don't. I'm not going to bill you at all." I said "I'd really rather you just bill me in network" and she said it was already done out of network and couldn't be changed. I didn't know what to do, so I left.
So basically, this is insurance fraud, correct?
I've already decided not to go back to this doctor (especially because I got a call a few days later that they biopsied my toenail--without asking whether to do so, or telling me they were going to do so--and pre-emptively scheduled me an appointment to come in and discuss the results: what am I, an insurance cash cow?).
However: I got in the mail today a 50 dollar check from my insurance company, and an explanation of benefits saying I owe the out of network provider 1500 and some change (which I'll never be billed for). The 50 dollar check is what they are reimbursing me. I feel very weird about this and I don't know what to do. If i don't cash the check, do i look suspicious? If I do, am I complicit in insurance fraud? Do I notify the insurance company about this (but if I do, am I going to be charged thousands of dollars by the insurance company itself, for the amount they paid the doctor over the in-network amount?) Or is this not that big of a deal and I'm over-reacting?
Please advise.
Don't cash the check. You know it's not rightfully yours, so don't cash it. Cashing it would be actually doing the wrong thing when, so far, you've done nothing wrong.
If I were you, because personally it really chafes me when people cheat the system (even extremely flawed systems like health insurance in this county), I would call the insurance company and rat this doctor out.
Call your insurer and ask to be promoted up the customer service chain of command until you're speaking with someone in a truly supervisory capacity. I'd try something like "I believe a doctor I saw processed a fraudulent insurance claim with my account and I need to speak to a supervisor please." This isn't what the company will want to do, but just be insistent, calm, and clear, and repeat yourself until they transfer you to someone with a title. (It's either that or explain the story 10 times to 10 different people who can't help you, which will take forever and would piss me off.)
Once you're actually talking to the right person, explain the facts. Don't say you were naive, don't say you were woozy from your toenail, just explain exactly what happened without any embellishment or editorializing. That you found the doctor with the provider finder tool, what your doctor said to you, what your doctor said happened, what you paid or didn't pay, what you received. It's not your job to make sure the doctor is being forthright--you've done nothing wrong.
You should also call the insurance company as a CYA measure in case the doctor decides to bill you for the $1500 a few months down the road.
Save all the paperwork you have, the insurance company may want you to send them a copy.
Hold off on leaving a yelp review until after you've spoken with the insurance company but I would also be tempted to leave a negative yelp review explaining that the doctor and practice are being underhanded and vague about their billing practices.
posted by phunniemee at 10:37 AM on October 13, 2015 [15 favorites]
If I were you, because personally it really chafes me when people cheat the system (even extremely flawed systems like health insurance in this county), I would call the insurance company and rat this doctor out.
Call your insurer and ask to be promoted up the customer service chain of command until you're speaking with someone in a truly supervisory capacity. I'd try something like "I believe a doctor I saw processed a fraudulent insurance claim with my account and I need to speak to a supervisor please." This isn't what the company will want to do, but just be insistent, calm, and clear, and repeat yourself until they transfer you to someone with a title. (It's either that or explain the story 10 times to 10 different people who can't help you, which will take forever and would piss me off.)
Once you're actually talking to the right person, explain the facts. Don't say you were naive, don't say you were woozy from your toenail, just explain exactly what happened without any embellishment or editorializing. That you found the doctor with the provider finder tool, what your doctor said to you, what your doctor said happened, what you paid or didn't pay, what you received. It's not your job to make sure the doctor is being forthright--you've done nothing wrong.
You should also call the insurance company as a CYA measure in case the doctor decides to bill you for the $1500 a few months down the road.
Save all the paperwork you have, the insurance company may want you to send them a copy.
Hold off on leaving a yelp review until after you've spoken with the insurance company but I would also be tempted to leave a negative yelp review explaining that the doctor and practice are being underhanded and vague about their billing practices.
posted by phunniemee at 10:37 AM on October 13, 2015 [15 favorites]
Definitely a violation of the provider's contract with the payer, so it's probably fraud on her part. Should you care to fight it, you can call your insurance company and explain that you were under the impression the provider was in-network. Make them make her resubmit the bill so it's applied properly to your in-network benefits (she's wrong to say the bill can't be changed now- of course it can! providers submit revised bills all the time, and payers process them!). I agree with muddgirl that it's possible the provider is full of it and the practice is, in fact, going to bill you for the balance, so it's in your best interest to not ignore the issue.
posted by ThePinkSuperhero at 10:45 AM on October 13, 2015 [4 favorites]
posted by ThePinkSuperhero at 10:45 AM on October 13, 2015 [4 favorites]
she's wrong to say the bill can't be changed now- of course it can! providers submit revised bills all the time, and payers process them!
I missed that bit of shameless lying. Of course she could change how she billed it! I have a specialist who has been resubmitting amended bills several times over the past year (against a policy I no longer have!)
posted by muddgirl at 10:56 AM on October 13, 2015 [2 favorites]
I missed that bit of shameless lying. Of course she could change how she billed it! I have a specialist who has been resubmitting amended bills several times over the past year (against a policy I no longer have!)
posted by muddgirl at 10:56 AM on October 13, 2015 [2 favorites]
Don't necessarily call the insurance company to "rat her out". You can just call them to ask what you asked here, minus mentioning the phrase "insurance fraud". You legitimately are confused, don't understand why the doctor is saying she'll never bill you the $1500, don't know how you can be sure she won't, don't know why she's billing through an out-of-network practice, and are wondering why the insurance company sent you a check for $50.
However - make peace with the idea that the doctor, her other patients who maybe don't pay much because they are uninsured, and the health landscape of your particular area (are there other podiatrists locally who can and do follow the rules, or will this person being thrown out of the network mean no foot care for three counties?), may be affected by what you do.
Having a system with fair rules that are followed as transparently as possible is very important, but some people might be inconvenienced (for varying degrees of "inconvenience", including real problems) in the short term. In other words, this is an important decision for you, but I hope you don't just make your choice based on what will upset the fewest people.
posted by amtho at 12:18 PM on October 13, 2015 [8 favorites]
However - make peace with the idea that the doctor, her other patients who maybe don't pay much because they are uninsured, and the health landscape of your particular area (are there other podiatrists locally who can and do follow the rules, or will this person being thrown out of the network mean no foot care for three counties?), may be affected by what you do.
Having a system with fair rules that are followed as transparently as possible is very important, but some people might be inconvenienced (for varying degrees of "inconvenience", including real problems) in the short term. In other words, this is an important decision for you, but I hope you don't just make your choice based on what will upset the fewest people.
posted by amtho at 12:18 PM on October 13, 2015 [8 favorites]
By the way, it is also insurance fraud to bill the insurance company for the entire charge and then forgive the co-pay.
If the insurance company decides that it should have been billed as in-network instead of out of network, even if they don't treat as a fraud, they will certainly recover the overpayment from the doctor.
In your shoes, I would probably call the insurance company and just ask why it is coming through as out-of-network when you deliberately chose to go to an in-network doctor. I probably wouldn't get into them not collecting the co-pay just because it is more a mess than I personally would want to get involved in. If insurance company wants to question other bills from the same doctor and look for a pattern of over-charging - that is up to them, you are just giving them the clue that there is a problem as well as making sure you aren't colluding with their fraud.
posted by metahawk at 2:16 PM on October 13, 2015 [1 favorite]
If the insurance company decides that it should have been billed as in-network instead of out of network, even if they don't treat as a fraud, they will certainly recover the overpayment from the doctor.
In your shoes, I would probably call the insurance company and just ask why it is coming through as out-of-network when you deliberately chose to go to an in-network doctor. I probably wouldn't get into them not collecting the co-pay just because it is more a mess than I personally would want to get involved in. If insurance company wants to question other bills from the same doctor and look for a pattern of over-charging - that is up to them, you are just giving them the clue that there is a problem as well as making sure you aren't colluding with their fraud.
posted by metahawk at 2:16 PM on October 13, 2015 [1 favorite]
If your insurance company finds out she's doing this on the regular they'll drop her. Which doesn't seem to matter to her.
posted by emkelley at 3:42 PM on October 13, 2015
posted by emkelley at 3:42 PM on October 13, 2015
Your insurance company may have a phone number just for fraud situations. You may be able to report the provider anonymously. Assuming you do report it anonymously your insurance company may or may not end up reviewing your claim. It depends on how much effort they put into fraud detection/prevention. Also depending on much control they have over the network they may not keep the provider in the network.
What your provider did is call No Out of Pocket Expense and is fraudulent. In my experience insurance companies pay out of network benefits based on the amount you were actually charged up to a hard limit sometimes referred to as usual and customary. They also factor in copays, deductibles, and co-insurance percentages, but the base amount is what the provider is charging you as there doesn't exist a "claim" beyond that amount. When the provider doesn't truly charge you this amount the insurance company definitely will take the view that they owe less.
If you call to ask about in vs out of network, be aware that depending on how the network is orginized provider participation may be based on both treating provider and location. However if they agree that it should be in-network, they will definitely reprocess the claim and makes adjustments.
Worst case scenario for you is the insurance company doesn't consider the claim in-network but adjust their benefit based on the provider not billing you. That will most likely results in the insurance company requesting a refund and/or the provider billing you.
posted by Shanda at 3:52 PM on October 13, 2015
What your provider did is call No Out of Pocket Expense and is fraudulent. In my experience insurance companies pay out of network benefits based on the amount you were actually charged up to a hard limit sometimes referred to as usual and customary. They also factor in copays, deductibles, and co-insurance percentages, but the base amount is what the provider is charging you as there doesn't exist a "claim" beyond that amount. When the provider doesn't truly charge you this amount the insurance company definitely will take the view that they owe less.
If you call to ask about in vs out of network, be aware that depending on how the network is orginized provider participation may be based on both treating provider and location. However if they agree that it should be in-network, they will definitely reprocess the claim and makes adjustments.
Worst case scenario for you is the insurance company doesn't consider the claim in-network but adjust their benefit based on the provider not billing you. That will most likely results in the insurance company requesting a refund and/or the provider billing you.
posted by Shanda at 3:52 PM on October 13, 2015
It sounds like she was planning on giving you a discretionary discount so you would not receive a bill. She will either remember to do that or forget and you will get a bill for the balance since (some portion of your visits) was already billed out of network per your insurance reimbursement statement.
Also, the already billed and reimbursed portion sounds sort of like it was only for the initial visit. The doctor may have realized after your initial visit that the practice was out of your network, so decided not to bill for the follow ups (by making you "self pay" then giving a 100% discount), but is feeling that the expense of her service to the practice will be covered by the out of pocket portion you owe from the initial visit.
Non of that would be fraud by the way.
posted by WeekendJen at 8:32 AM on October 14, 2015
Also, the already billed and reimbursed portion sounds sort of like it was only for the initial visit. The doctor may have realized after your initial visit that the practice was out of your network, so decided not to bill for the follow ups (by making you "self pay" then giving a 100% discount), but is feeling that the expense of her service to the practice will be covered by the out of pocket portion you owe from the initial visit.
Non of that would be fraud by the way.
posted by WeekendJen at 8:32 AM on October 14, 2015
This thread is closed to new comments.
I really, really doubt that you are not going to receive a bill for $1500 from the practice in the coming days.
posted by muddgirl at 10:32 AM on October 13, 2015 [6 favorites]