Medical billing shenanigans. What recourse do I have, if any?
October 10, 2016 8:05 AM   Subscribe

I was billed for a surgical procedure that my doctor never performed. When I complained and asked for a refund, they instead raised the price of a different procedure listed on the same bill, so that my total bill still came to the same amount. What recourse do I have?

Several months ago I had a complicated surgical procedure done. My itemized receipt from the surgeon, when I received it, looked like this:
Whatnot surgery $8,000
Bilateral foobarectomy $3,500
Bazplasty $1,500
Quuxplasty $1,500
Whatnotectomy $1,000
Thingumaplasty $1,000
Total $16,500
This surgeon never performed a bilateral foobarectomy on me. I had my foobars removed in a separate procedure years ago. When I pointed this out, and asked for a refund of that $3500, my surgeon's office manager told me she was unable to give a refund, but that she would be happy to provide me with a new receipt that looks like this:
Whatnot surgery $11,500
Bazplasty $1,500
Quuxplasty $1,500
Whatnotectomy $1,000
Thingumaplasty $1,000
Total $16,500
My questions:
  1. Is this even legal?
  2. Do I have any realistic recourse here? If it matters: the surgeon is not in-network with my insurance.
posted by nebulawindphone to Health & Fitness (17 answers total) 2 users marked this as a favorite
Do you have both bills? because I'd take both to a lawyer and explain the situation.
posted by INFJ at 8:07 AM on October 10, 2016 [5 favorites]

(I have not yet received a receipt that looks like #2. My surgeon's office verbally offered to send a receipt that looked like that instead of sending a refund.)
posted by nebulawindphone at 8:09 AM on October 10, 2016

(Also, in case it is relevant and in case it was not clear, I have already paid the $16,500.)
posted by nebulawindphone at 8:11 AM on October 10, 2016

This sounds sketchy to me, and for that kind of money, I'd probably do a lawyer consult too. (Especially if you perchance have access to some free lawyer time via an employee assistance plan.)

I don't honestly know how successful you'd be - I'd be worried they could just say "oh, the first receipt was an error in our coding, the second one is the correct one." So if you've got any kind of earlier documentation breaking down costs that would support the first receipt (from earlier discussions with the doctor, prices off their website, anything?) I'd pull that together too, to minimize any chance they can pull that off.
posted by Stacey at 8:21 AM on October 10, 2016 [1 favorite]

On first impression that does look like breach of contract and civil fraud, and depending on your jurisdiction it may also violate other laws. This is a reach but it may possibly also be medical malpractice. More facts are needed to say one way or the other.

I am guessing that in their defense, the doctor will claim something along the lines of a standard billing rate per minute in the operating room suite, and that the total bill is the same either way. A review of the medical records for the procedure, and the hourly and billing records for the surgery suite would help test that claim.

Assuming you are in the USA, a Plaintiff's side lawyer may be willing to take this case on contingency, that is, they will help you and you will only pay them a portion of your winnings if you win the case.

If you don't want to use a lawyer or can't find one, you might contact your state medical association and the government agency in your state that licenses doctors to see if they can help you bring a claim against a doctor for billing for a procedure that did not happen.
posted by PlannedSpontaneity at 8:26 AM on October 10, 2016

You are effectively disputing a $3.5K charge. Although the total bill is larger, your actual dispute is over a smaller amount. I am pointing this out because this is (well) within the small claims court guidelines of every state that I am familiar with, including Massachusetts.

Given the small amount, I question whether a lawyer is worth it. Either the lawyer takes the case on contingency and it costs you $1,167 (33% contingency fee) or they don't and it costs you several hours of their time (probably approaching the same amount). In addition, if the facts are as you describe them (which I can't evaluate), then the court case should be very easy for you to win - just show the bill and show documentation from when the procedure was actually performed on you.

To be honest, I would be surprised if you weren't immediately offered a settlement that is at least higher than you'd get with a lawyer involved before you even get to the court room.
posted by saeculorum at 8:37 AM on October 10, 2016 [6 favorites]

What did the initial $16,500 payment include? If $16,500 was the lump-sum cost for the services you needed, and all of those services were rendered, why would you be due a refund just because they accidentally included an extra service in your invoice? You should speak to a lawyer if you feel you are being defrauded, I just don't see why you would be due any money back if you got everything you paid for.
posted by ThePinkSuperhero at 9:10 AM on October 10, 2016

It sounds to me like a "Whatnot surgery" costs $11,500 and normally includes (by necessity) a "Bilateral foobarectomy." Whether that means the foobar is attached to, part of, or on top of the whatnot is unclear to me, but I'm not a medical professional. Regardless, they can't operate on your whatnot without removing your foobars.

To avoid confusion where someone might wonder if they removed the foobars during the whatnot surgery, they include it as a line item. As you had no foobars to remove, including it as a line item made no sense to you. The implication is that the work that would normally be done to remove foobars is done when doing general whatnot surgery regardless whether they are present.
posted by mikeh at 9:18 AM on October 10, 2016 [1 favorite]

Did you pay by credit card? You may be able to do a charge back for the disputed amount & let them argue with the credit card company to prove it's not a rip off instead of you. I say this as someone not very familiar with US medical billing, which may well have it's own arcane laws in the USA, but as someone that has dealt with various dodgy invoices in her time bookkeeping. Be prepared with copies of all the relevant paperwork & communication to send to the card company to prove your case.
posted by wwax at 9:35 AM on October 10, 2016

First make a written claim to the doctor's office for a refund, explaining the history from scratch and expressing your consternation about having the price of one billed procedure raised in response to your reminder to them that a second billed procedure had not taken place. Ask them to issue a refund immediately, or to explain fully, in writing, why this can not be done.

Chances are, this will do the job. If it doesn't, find a lawyer who will write a similar demand letter, which you can largely script for them, it shouldn't cost more than a half hour's worth of their time. That letter should include the further steps you intend to take if the refund is not forthcoming, including small claims court and a report to the Massachusetts Board of Registration in Medicine.

If that doesn't do it, follow through on those further steps. What they may claim along the way, as suggested by others, is that the charge is really for the whole procedure and they just erred in how they described it. You should look for evidence to the contrary. Possibly, for example you can obtain a procedures price list from that office by enlisting some help from your employer's HR department and the insurance company, even though this was out of network and presumably not covered even partially by your plan.
posted by beagle at 9:49 AM on October 10, 2016 [1 favorite]

Doesn't your state have a list of cost per procedure doctors need to adhere to? Can you find that list?
posted by LoonyLovegood at 9:50 AM on October 10, 2016

Request a list of costs for procedures. Request a bill that accurately states exactly what was performed, and bills accordingly. Contact the medical consumer affairs department of your state's attorney general's office, they'll have a web page. If you had an elective procedure and agreed to that price ahead of time, then it's probably fair. Otherwise, this is very sketchy,
posted by theora55 at 10:15 AM on October 10, 2016

Is this insurance that you got through your company or did you buy it yourself? If you got it through your company, get them involved (I did this years ago with a bizarre billing issue).
posted by It's Never Lurgi at 10:35 AM on October 10, 2016

I'd try again with the billing department and start corresponding by email or the like so that you have a paper trail on this.

In my limited experience, medical billing departments start backing up once they see you're actually serious, especially if you're paying out of pocket.

In fairness to them: I myself bill for complex procedures (technical, not medical, i.e. software development) and used to get caught in the ticklish situation where my costs are the same whether the foobarectomy procedure was done or not, but we have customarily shown that as a discrete charge and/or put that in as a matter of course, assuming that the foobarectomy ALWAYS comes standard with the whatnot. So that then when the customer has complained about the foobarectomy, or argued that it didn't happen/did them no good because of a rare situation, I was legitimately out money that was due me because we shifted a cost. Over time I got the company to quit doing it for just this reason (and also because it implies that our billing practices were sloppy, in that costs were not allocated to the procedures correctly)

Not that this makes it your fault or your problem; just pointing out a scenario where grand fraud is not necessarily the operative mode they're running in.

On reread of the thread - what theora55 said should be kept in mind. For example let's say you got laser eye surgery or some sort of elective cosmetic/plastic surgery and there is an "advertised price" for the job. Well, if you agreed to pay the price, it's kind of splitting hairs to read a detailed bill and say "hey, I didn't get (or need) this one particular little thing".
posted by randomkeystrike at 11:09 AM on October 10, 2016 [1 favorite]

Did this get billed through your insurance company? If so they should be able to review if the bilateral foobatectomy was completed or not through a chart review. You might want to tip them off to do that.
posted by MultiFaceted at 11:19 AM on October 10, 2016

If you don't have luck getting answers on what's happening through the office or your insurer, and you are in Massachusetts, the state's AG office is set up to take your health-care related consumer complaint right online, and you can also contact the state Office of Patient Protection.
posted by blue suede stockings at 11:34 AM on October 10, 2016

Whenever I have had medical procedures that involve surgery and/or bills of more than a few hundred dollars, I have been provided with an estimate of the cost of services ahead of time and I have had to agree to pay for the services rendered within a specific time frame. I have to imagine that you were provided a total cost for the experience or else you would not have paid for the care before receiving an itemized receipt. Does the total billed, regardless of how it adds up, come close to what you agreed to pay ahead of time?
posted by peanut_mcgillicuty at 7:12 PM on October 10, 2016

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