Insurance is billed for procedures I didn't receive
April 6, 2016 7:20 PM   Subscribe

I think my doctor is billing my insurance company for procedures that I did not undergo. Should I do anything about this?

I am receiving injections to deal with some back injuries. After every visit, I get an EOB from my insurance company, with a big check enclosed that I am supposed to pass on to the doctor's office, and a list of procedures I supposedly underwent. However, I definitely never underwent these procedures. For example, an office visit for some injections is billed with the three line items "Surgery-Neuro", "Office Visit", and "Radiology-Spine".

The total costs are multiple thousands; e.g. on this bill it's ~$5000, with a breakdown of $1000 paid by insurance and $4000 listed as "total you pay (or may have paid)". The insurance then sends me a check for $1000, and the doctor's office only asks for that $1000 check, not for the $4000.

I really like my doctor, and he helps me with my injuries immensely. But I'm a little morally conflicted about this, and worried it might bite me in some way going forward. Should I be worried? Should I do something about this? Or maybe it's all fine, and doctors often bill insurance companies for procedures based on some kind of "it's probably about this expensive" metric instead of based on actual procedures performed?
posted by Jacen Solo to Work & Money (18 answers total)
Can you take a look in your medical record and see if those billed procedures are in there and whether they have any reports/results/notes or anything?

Your medical record and what gets billed should match. This could be one way to look into it.

If your insurance is being billed for services that you didn't receive I can see how it could effect your usage, maybe deductibles, or any limits you may have (some have limits on the number of times you can receive a service or dollar amount?).

You can always call up your insurance and feign ignorance about all the EOB's and see where the conversation goes. Unless your doctor is family, like close family, sorry...but you don't owe them anything other than what they're getting paid to treat you.

If something truly fishy was going on I'd want to stay away from it. Your health issues are enough to deal with, you don't need to deal with insurance fraud on top of that (even though it would be your doc and not you).
posted by eatcake at 7:30 PM on April 6, 2016

If you're not paying what your doc is telling the insurance you're paying, that looks like complicity in insurance fraud to me. Absolutely report or ask about it.
posted by Lady Li at 7:36 PM on April 6, 2016 [6 favorites]

Not exactly the same, but seeing a large bill amount that your dr is not asking you to pay reminded me of this question. Folks seemed to agree that one was fraud.
posted by kapers at 7:37 PM on April 6, 2016 [1 favorite]

I wouldn't worry too much about this - insurers have pretty intricate systems that flag claims and bounce them back to the doctor if something seems amiss. Given that what you are having done is probably a relatively common procedure, your insurance company surely has reams upon reams of internal guidelines and algorithms about how to handle the claims that your procedure generates when they hit their systems. Essentially, if this code is missing from this claim - deny; if this code is in this position but this code is over there - deny; and so on. But, yes, this is generally how medical coding works - "it's probably about this expensive" is about right.

If you can tell us more about the line items - CPT codes would be a good place to start, but ICD procedure codes and revenue codes are cool, too - that would go a ways towards helping clarify what's going on.
posted by un petit cadeau at 8:00 PM on April 6, 2016

Some procedures are billed with multiple codes, so that is not unusual in and of itself. What seems like one procedure to you may, in fact, consist of three separate things. I would call and ask your medical office (or in person next time you show up) to go through the bill line by line. There is no reason they can't or won't do that for a patient. If they can't help you or if you're left confused or unsatisfied with their explanation, then you have a problem and need to contact your insurance.

The remaining balance that the office isn't billing you for may be a write-off on their part, for whatever reason, or something related to your insurance plan and how they're contracted with your provider. It's also possible your provider isn't contracted with your insurance or terms have changed, but that seems unlikely in the middle of the year. I would also inquire about the balance issue with your provider first, and then the insurance if you have remaining questions or doubts.

For what it's worth, I've been to a provider where the office billed for flat amounts per procedure. When the insurance came back saying so and so amount goes to your deductible and so this is what you owe the office, the balance was higher than what I had paid. I called the medical office to see if I owe them the remaining balance and was informed the flat fee was what they charged regardless of what the insurance did because they were not contracted, so even though my insurance applied x amount to my deductible, I did not in fact owe them that larger amount.

Fraud is not out of the question but doesn't seem like the most reasonable explanation because it's a huge risk for a provider (including prison time, can be considered a felony) and the provider knows that patients get EOBs from their insurance, often times even before the provider gets their copy. Also, procedures that cost thousands of dollars likely would require documentation from the provider when they submit the claim or it would be denied. You should request the medical report from your provider, as well, when you contact them.
posted by atinna at 8:00 PM on April 6, 2016 [6 favorites]

However, I definitely never underwent these procedures. For example, an office visit for some injections is billed with the three line items "Surgery-Neuro", "Office Visit", and "Radiology-Spine".

IANAD, but what's considered "surgery" for billing purposes can sometimes be counter-intuitive. I was once had an ENT pull a plug of wax out of my ear, and *that* little in-office procedure that involved no cutting or piecing of any kind was billed as surgery. I questioned it with both the doctor's office and my insurer, and both told me this was normal.
posted by jon1270 at 8:02 PM on April 6, 2016 [4 favorites]

What you're being billed for looks like what might be an epidural steroid injection which is something done for back pain. The bill may be correct.
posted by Carbolic at 8:05 PM on April 6, 2016 [2 favorites]

It's never been my experience that insurance sends me a check that's supposed to go to the doctor. When I get an insurance check, it's because I paid the doctor more than I had to, and the insurance is reimbursing me.

It sounds like the doctor is reporting that you paid him a lot of money, and the insurance is paying you back for overpaying him. Except that you didn't pay him anything. It sounds like insurance fraud to me.
posted by spacewrench at 10:16 PM on April 6, 2016 [2 favorites]

I don't know about the checks you're getting, and it's definitely worth asking about. Many medical practices have someone on staff whose job is to coordinate claims with the insurance company, make sure that certain procedures are covered, etc. You might ask your doctor's office if they have someone like this that you could talk to.

IANAD, but I work for an insurance company and I read and analyze a lot of medical records as part of my job. The three things you listed all look pretty typical to me. There's one charge for the visit itself (office visit), one charge for whatever x-rays, MRIs, or CT scans you may have had (radiology), and one for the injection itself. This is actually considered a type of surgical procedure even though it's done in the office. Pretty normal.

The checks, though, that's a little weird. If the doctor's office has an insurance liaison I would ask them about that part of it. It sounds sort of fraud-y, but there could just as easily be a legitimate explanation for it. If you don't get a straight answer from the doctor's office, or you don't understand their answer, I would call the health insurer and just ask what the heck is going on.
posted by That's Numberwang! at 10:52 PM on April 6, 2016 [2 favorites]

It is normal to get checks from your insurance company. Most people have signed assignation of benefits forms, which allows the insurance to send the check directly to the doctor.

It's in he raft of paperwork the doctor's office makes you fill out. This is done as a courtesy to patients who then are paying whatever the insurance doesn't cover. (And yes, some practices can make it on the fees collected from your insurance without collecting 'the rest' either because you have really great insurance or because their cash patients pay through the nose) But many offices trust the patient to bring in the check. And other offices require you to pay for the procedure and then the patient gets reimbursed by the insurance.

It is also possible that this is insurance fraud, but having worked in medical and having managed dental practices, I wouldn't be quick to rubber stamp this as 'definitely fraud' because medical coding is complicated and might definitely look suspicious to patients.
posted by bilabial at 12:23 AM on April 7, 2016 [1 favorite]

That wasn't clear. It's normal for the patient to receive the check and then sign it over to the insurance company. Or deposit it and then write your own check to the doctors office. But more likely just sign over the insurance check.

Very normal.

Whether the coded procedures were actually performed, we cannot say. But it's possible.
posted by bilabial at 12:25 AM on April 7, 2016

It is totally normal to call the doctor's billing office (not the doc, they won't know) and ask which procedure went with which code. My mom worked in medical billing most of my life and answering these questions was a big part of her job. "injection coded as surgery" is exactly the kind of thing that turns out to be normal and explainable. Insurance coding is total nonsense viewed from the outside but they should be able to tell you what is what.
posted by tchemgrrl at 3:21 AM on April 7, 2016 [1 favorite]

The "radiology-spine" is undoubtedly what is known as fluoroscopic guidance. The physician uses an x-ray-like device in real time to show where the needle is being inserted so that he knows it is where it should be.

A common approach to medical billing is

1. submit an entirely outlandish charge
2. see what the health insurer will pay
3. take it
posted by megatherium at 4:34 AM on April 7, 2016 [2 favorites]

Thanks all. Although there is a variety of answers, it seems like there's at least a number of reasonable explanations. An injection as "surgery" seems somewhat plausible as an artifact of medical coding. The "radiology" bit was the missing piece to me, since there was no radiology done but instead just a needle, but megatherium's explanation sounds like a plausible way to fill in that gap.

I'm certainly less worried now. Combined with how this doctor is very helpful to me, I'm inclined to not make a fuss.
posted by Jacen Solo at 6:58 AM on April 7, 2016

This is the part that is very possibly (likely, I think) fraudulent: "The insurance then sends me a check for $1000, and the doctor's office only asks for that $1,000 check, not for the $4000."

Your insurance company would not be happy about that. The doctor has made a false claim to the insurance company that he has charged you $5,000, which they used as the basis for calculating the amount of the reimbursement to you. In fact, though, your doctor has not charged you $5,000; he has charged you only $1,000.

I have no idea whether you have any responsibility to do anything about this, although my guess is you do not.
posted by merejane at 10:00 AM on April 7, 2016

If it helps, I recently had injections in nerves near my spine, and then eventually rhizotomy (selective destruction of nerves), and those three categories were exactly what were billed to my insurance. As was mentioned above, they do real-time imaging during these injections.

If you're concerned about the $1000/$4000 thing, call the billing person at your doctor's office. They can help you understand why the office is asking only for the amount your insurance will reimburse and not more. You don't mention whether you have received an Explanation of Benefits separate from this check, but if not, see if you can get one. It might also clarify if there's an insurance write-off going on. I find that doctors' bills are usually less informative than EOBs for explaining exactly how the money worked out.
posted by not that girl at 12:22 PM on April 7, 2016

If the doctor is not contracted with the insurance company - which it sounds like since insured is getting the checks, not the doctor, how is the 1000/4000 dollar question any different than when a doctor *is* so contracted, submits a bill for 4 grand, and the insurance company whittles it down to 1k, because this is what I see on my EOB's with in-network physicians.
If the billing is on the up and up, what is the problem with the doctor settling for less than their bill?
Example - I needed an MRI. In network with insurance it was something like 2K, but my copay was only 800 bucks.
Because my insurance was being a real PITA (back?) about approving the procedure, I called the provider and asked "How much if I pay in cash?"
answer? 800 dollars.
posted by rudd135 at 4:29 PM on April 7, 2016

Your EOB should include CPT codes , they're five digits although I've seen EOBs that include extra modifiers afterwards.
"Surgery-Neuro" - this should start with a 6 probably (Any CPT code that starts with a 1, 2, 3, 4, 5, or 6 is in the Surgery section of the CPT book)
"Office Visit" - Should start with a 99 and probably has a 25 after it
"Radiology-Spine" - Should start with a 7 (All radiology procedures start with a 7)

The office visit charge could actually be fraudulent. If the visit is solely to do the injection, then they are not going above and beyond the minimum amount of evaluation and management necessary to perform the procedure to report it separately as an Office Visit. It could also very well completely above board. Without actually reviewing medical records, it's impossible to say.
posted by Apoch at 4:57 PM on April 7, 2016

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