Posted: 6/16/2006 3:16:09 PM EDT
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January 24, 2005 I had some surgery in my nose so I could breathe better. Today I got a bill from the surgeon. WTF?  I start digging through all of the paperwork from a year and a half ago. The bill lists two dates of service, and the amount of the charge. What I find in my papers looks odd. It appears that in February 2005, my doctor's office billed my insurance for two seperate items on two seperate "dates of service". My insurance company paid all but the copay. In March 2005, the doctor's office bills my insurance company again, for the same dates of service, and for the same dollar amount. And again, my insurance company paid all but the copay. And now the doctor is sending me a bill for the same thing. It appears they have already been double dipping with the insurance company. All of the offices are closed, or I would call. But this sure seems like something is fishy. |
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Almost certainly an error in the Dr.'s accounting department. Very common these days. Think about it, if they were double-dipping your Insurance Co., the last thing in the world they would do is send you another bill to raise your suspicions. The Insurance Co. processes most things automagically and it would be really easy to double-dip (Medicaid Fraud anyone?) from the Insurance Co., but patients actually look at their bills so you wouldn't want to send anything to the patient that would make them call the Insurance Co. with a heads-up. Futuristic |
| It is likely an attempt at fraud that when discovered (or reported) to the insurance company will be dismissed as an error in billing from the doctor's office. This is how doctors make up for the limited reimbursment they get from managed care organizations. Insurance companies never persue these cases legally out of fear of generating bad PR with their providors. |
Most doctors have no idea about the billing. The billing gets sent out to a biller company that bills the insurance and patients. The doctors get what ever they collect minus a 5-8% collection fee. So the doc usually doesnt know what was billed. Its always interesting to see the patients bill and compare it to the insurance. The insurance companies also pay extremely long delaying games with the doctors. Its not unusual to have accounts receivable out to 3-6 months. Also what the insurance is telling you isnt what is true. They maybe withholding payment to the doctor. After a month the docs dont get paid, and they bill again. The insurance may indicate to you that they paid, but in actuality they promised to pay but write it off as paid. The doc will get some of the money eventually. Since the billing company gets a percentage of the billing, they are aggressive about rebilling over and over until some money hits the till. Some of the HMOs will not pay EVER. United Health and Omnicare are two that did that for a significant amount of time before filing for bankruptcy or being sold to other HMOs. I can almost guaranty thats what happened to you. Call the doc and is if they actually got paid. |
Thats total BS. If a doctor is convicted of fraud he can lose all access to all the patients in that group and others. If you are blacklisted from seeing a large portion of the patient base then you might as well close shop. Its very rare for intential fraud to occur, most of the time its a billing error. There always bad apples in any group and some docs have made lots of money with fraud. But usually it ends up with JBTs sealing an office and taking all the records. The insurance companies are in no way frightened of any doctor. In fact, they review random charts for every doctor in their contract group to make sure standards are being met and that no fraud is occuring. This will will occur once, twice or even three times a year. They are more then happy to freeze all billings with even a hint of fraud. |
<CoC violation edited out--Aimless> Still a ridiculous and foundless accusation. Can that brush be any broader.
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Sorry I missed the 'CoC Violation' comment, and perhaps my statement was a 'broad stroke' with the brush. However... people are naive if they think that insurance fraud (incorrect billing by doctors) occurs rarely as opposed to frequently. Also, be assured that this occurs far less likely when patients use private insurance companies or indemnity plans that pay whatever ridiculous fees the doctor bills for rather than the 'usual and customary' fees that MCOs pay doctors for their services. I'm not a doctor, and I have no need to discuss why/how I know this. I can tell you though, that I was having dinner with a claims investigator for a MAJOR insurance company and he told me that almost never do they legally persue these fraudulent claims b/c they're very difficult to prove, and in the WORST CASE SCENARIO they will terminate any contractual relationship they have with the phsyician/providor. |
Well he isnt telling you everything. They RANDOMLY come into a office and AUDIT charts. He didnt tell you that did he. You really think in the day of computers they would not pick up multiple billings instantly? What he really investigates is how to prove a case so they can deny a patient their right to care so they company doesnt have to pay. Its amazing how many patients are stuck will a bill that the insurance company will not pay. They will deny it over and over again hoping that the patient or the doc will get tired of it and pay it themselves. Usually after the third appeal they will pay. |
I'm not arguing any of your points. All I'm saying is that doctors are no less prone to commit fraud/crime than anyone else and to believe that their career has any reflection on their moral character is obsurd. I have personally/professionally been involved in a federal case where MANY doctors were indicted on charges of fraud related to billing issues. They were caught as a result of a whistleblower and about 5 years worth of investigations. This ocurred in connection with a company I worked for several years ago. Although I never had to appear in court, I was personally visited by the FBI. |
Niceguymr-- You apparently have some "expertise"--or at least you are claiming to have some. I'd strongly tend towards the billing error. If you have a way to back up your statements with facts, please do so. Maybe an explanation of ICD codes and CPT codes? Electronic billing practices? Chronic UNDERBILLING by Doctors due to Medicare threats ("Fraud" is automatically assumed) and outside auditing agencies that get a percentage of what they report to gov.org as overbilling. My former Attending (now here in Allentown working at the same practice) was paid as a straight percentage of his net collections. He is paid by the practice within 2 weeks of the time the funds come in. He will be getting residual money for 6 months after quitting working because of how slow many insurance companies pay. AFARR |
Absolutely. There are huge cases especially involving medicaid in particular. Large well known companies have been dinged in the past. As well as lots of doctors. But your blanket statement really reveals your limited understanding of the billing process. Fraud is only a small portion of the billions of dollars that are billed every year. Even if you wanted to bill fraudulently, it very difficult. There are several checks and balances throughout the process. Not many doctors bill themselves anymore. If fact an objective non related billing company will handle the billing. A lot of doctors never see a bill or the cash. They get a check from what the billing company bills out and nets. ETA, Please offer some evidence of your assertions. I dont think you can. Just because you are stating it doesnt means that its true. Your statements are especially suspect since you refuse to discuss your assertions in any way. |
Although I have no need to, I will dignify you question with a limited response since I don't like revealing to much personal information in discussion forums. Next thing you know some relentless internet commando will figure out my name and other personal info and post it all over the place, which I do not care for nor need in my life. I once worked for a company that was being investigated by the FBI in connection with conspiring with physicians to commit fraud. There were many employees of my company as well as physicians who were indicted. Nobody was convicted since the fraud was very difficulty to prove, but a very heavy settlement was made any many doctors lost their licenses and/or other privilidges. Today, I have varying level of personal and professional relationships with people in a wide array of jobs in the healthcare system, including myself. Knowing what I know about the previous case that I was involved in coupled with my current an ongoing knowledge of today's healthcare system, there is no reason to think that the same type of activities aren't still ocurring. |
Since it happened to you, you conclude its happening everywhere? I think you have an overdeveloped sense of ego. Of course fraud occurs everyday. But not on the scale that you are asserting. Its a mere drop in the bucket compared the to the billions that are billed legally. Also I doubt any licenses were taken nor were there loss of priveledges. Why would they settle if that was the case? Jail you say? Why bother if you cant make a living. They may have paid back some of the money, but I really doubt it went any further. But huge corporations have been busted for fraud. The reason the whistleblower rat on the docs or company is because they get 15 to 30% of the amount in question. |
An East Texas doctor lost his license, and did jail time for insurance fraud and tax evasion. |
I own a part of a medical billing corporation. ETA: But my facts are facts not assertions gleaned from one isolated personal experience. I deal with this everyday. I am also in close contact with 2 complicance officers for 2 separate hospitals in my area. We deal with this everyday. |
With all due respect, how could you possibly know if a doctor submits false "appointments" for you to bill? Do you have staff in the doctors office? Just wondering, because you seem to think there is no way this could happen. 
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This explains your position quite well. Thank you. |
+1 And I would also like to add that I am part owner of many business that participate in activities I would have absolutely no knowledge of. |
On the contray if you read my post it happens everyday. But not on the scale or widespread as mrniceguy is stating.  The best example I can give you occurred recently. A lady doctor would tell her patients that they had to pay so much $$$$ to keep seeing her. She is muslim and so are most of her patients. Most of her patients are also on medicaid, thats another issue that needs to be discussed. But anyway, the muslim women only want to see women doctors. Its not in their religion but most of them claim it is. So this doc tolds these women they would have to pay for the priveledge. $1000 each from my understanding. She made thousands and thousands of dollars until she got busted. The FBI swooped down and took everything and anything with writing on it. At her office and at the hospital. So it happens but not that often and not so widespread. But there are thousands of doctors and a few will be bad. Thats with any profession. The majority are law abiding. But his statement might as well said all gunowners are psycho and snipe on innocent people since the judge got shot. |
They were indicted so they must be guilty! You're a prosecutor's wet dream.
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Well thats truly a sad statement. Because if you dont mind your business ventures you will end up in jail. Your professed ignorance will not be a defense when you are indicted. |
I'll agree with you that the majority of doctors do not knowingly attempt to commit fraud, and that my statements can be correlated to the above statement about gunowners (which was not my intention). Can we just agree that it happens? What I may think is a lot of occurrences, you might think is very few. BTW... Did you catch the stats on the occurrence of fraud against FEMA after hurricane Katrina? It's something like 1 Billion Dollars (possibly more) out of about 6 Billion Dollars. Clearly, the majority of people did not try to defraud FEMA, but plenty did. |
Yep this is a point of view arguement. One persons pebble is another persons boulder. |
If you read more carefully you would see I agree with you and I stated it happens everyday! Just not on the huge scale that you think.  But unlike the Katrina victims there are tremedous checks and balances that are in action every step of the way. |
I guess I should sell off all my stocks and mutual funds since some of the companies that I invest in may be committing fraud that has not yet been discovered. Lots of people own businesses and rely on blind faith that their business is being run properly. It's nearly impossible to monitor all aspects of a business unless it is relatively small and you employ very few people. |
The way the market has been acting it might not be a bad idea. Some nice bonds are giving 12% return per year right now. A tad risky but not as risky as the market right now. |
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Well, I know of one case where I'm 99% sure it was fraud. My ex was on the birth control pill, dispensed by a local health clinic. It cost something like $36 out of our pocket, and we were told we had to pay up front because insurance doesn't cover the birth control pill. My ex saw so many doctors for so many things, that I never bothered to look at the insurance company's explanation of benefits. One day I did. And I saw that the clinic was billing them for the pills, and my insurance company was paying them something like 80%. I didn't catch this for a year or more. I called the clinic, and asked for an itemized statement of our account for the entire time that my ex was being seen by their people. It showed the cost of the pills being paid by us, and luckily it even recorded the check number I paid with. It also showed incoming payments from the insurance company. On the day that they issued the statement, the computer magically created a charge to the account that absorbed all of the money issued by the insurance company. I was totally ignorant about the whole thing, and still thought they were right. Until I called them to find out what the bill for over $400 was for, because I didn't remember anything happening that should have cost that much. The girl on the phone about choked. She said it must have been a billing error, and they would correct it. So I questioned the insurance payments that they got, even though I paid 100% of the cost. Again, she didn't know what to say. So they issued me a check for more than $400. They told me that my insurance was actually paying a portion of the bill, but the "computer system" didn't recognize I should have been paid back. It wasn't until later I found out that my insurance company was being billed for something other than the BC pill. They didn't cover BC pills at all. So I reported the clinic, knowing full well I was responsible for paying back the $400. They were screwing the insurance company, and in turn I screwed them. Although I didn't even know it until well after the fact. Best part was, nobody ever asked for the $400 back. And less than a month later, the clinic changed it's name, and moved to a new location. |
So it wasnt fraud it was stupidity in the billing. Not many insurances pay for BC pills anymore. |
16% fraud rate is no peanuts. You obviously know zero about insurance companies if you think they will let doctors (or homeowners or car owners) get away with even a single penny in fraud. |
No, it was fraud. The clinic told me outright my insurance company did NOT cover the pills, and not to even bother with submitting the claim. Then THEY submitted a claim, for prescriptions that we didn't even get. The money refunded to them by the insurance company was absorbed by fake charges to our account. If it walks like a duck, and quacks like a duck..... |