Doctor Lied About My Coverage to Make More Money for Herself

[glitski2]

My question involves insurance law for the state of: Maryland


My question is more about how to deal with my doctor lieing to me about my insurance. I can't find a section about medical.


I need to get little in-office surgeries and for the first couple years I trusted the doctor and what she said. So I was coming back over and over and over. And paying a $30 co-pay everytime! As well as dealing with stitches for months at a time.

I begged her this past time to do 2 at a time, she finally told me she cant because insurance doesnt cover it. So I called the insurance company and they saud I need the CPT code, so when I called the doc to get it, the receptionist actually refused to give me the code. I said if not the code for next visit (which I cancelled), give me the code for my last visit. Still refused.

So after lots of research from other docs, I got the CPT code and found out from insurance that they will cover 3 of these procedures per visit. So my doctor lied to me and caused me money in copays, as well as I spent months with stitches when I could have cut that time by doing 3 per visit instead of 1.

I found she gets 100% pay for the first procedure, 50% for second, and 20% for third. So by having me come back she is always getting 100% from insurance. But this was costing me $30 per visit as well as weeks of being unable to go to the gym, or pool, or take a bath, etc...

So I understand not telling me why she cant do more than one, but she flat out lied about why she cant do more than one when I begged her to do more

Can I do something about this? What are my options? I want to compain, but not sure who to send the complaint letter to?

Even if it wont get fixed for me, I dont want her doing this to other people who dont realize they can call their insurance to find their benefits.


Thanks!

[cbg]

I don't know where so many people get the idea that it is the doctor's responsibility to know what the insurance benefits for their patients are.

You don't want this to happen to other people who don't realize that they can call their insurance to find out their benefits? Well, spread the word, sweetie, because they not only can, it is THEIR RESPONSIBILITY to call their insurance and find out their benefits. It is NOT the responsibility of the doctor. Nor is the insurance bound by what the doctor said. And suing the doctor, which is what I assume you have in mind since you're posting on a legal site, is not going to change the fact that it was YOUR responsibility, not his, to call IN THE FIRST PLACE.

The doctor has, what, how many patients? Several hundred? Just why should he or his staff be responsible for calling the insurance company for all their patients rather than each patient making one phone call for himself? How do you expect the doctor to know what is covered on each individual policy? Not all policies by the same provider are identical, you know; I worked for one national provider and we offered a choice of several dozen options. And that was just for small businesses - when you add in the mid to large sized company's polices there were several hundred. And that was just for one insurance company. What makes you think the doctor can keep all those policies in his head? Are you prepared to prove that the doctor lied as opposed to just making a mistake?

I don't know who you can send a letter of complaint to since the doctor had no responsibility whatsoever to tell you what was covered. If you paid too much because you didn't pick up the phone yourself and ask a question WHICH IT WAS YOUR RESPONSIBILITY TO DO, that's not the doctor's fault, that's yours.

[glitski2]

I dont plan on suing, I just want think what she did was wrong and I want to do something about it.

They REFUSED to give me the CPT codes so I could do my research.


And the insurance company said it is very unusual for a doctors contract with the insurance company to not allow them to do multiple procedures.

I think my doc knows she was lieing, so she can get 100% of the money. I know, my fault for believing her and putting my trust in her, live and learn...

I dont want to sue, but I didnt know if their was something I can do. I'm sure I wouldnt win if I sued because I could have called insurance earlier, but I think she knows she was lieing and I just wanted to do something...

[cbg]

I've never heard of a doctor's office or hospital that would give you the CPT codes directly. What has always happened in my experience (and we're talking many, many years of it) is that the doctor's office would resubmit the claims with the correct (or corrected) CPT codes.

[lealea1005]

And the insurance company said it is very unusual for a doctors contract with the insurance company to not allow them to do multiple procedures.

Well, of course they say that! Then they call it "mutually exclusive" and refuse payment for all but the primary procedure.

Are you sure you got the appropriate CPT codes? Why couldn't you just get them from your EOB?

She did not lie. She doesn't get 100% of her fee each time. She gets 100% (then 50%, then 20%) of the "reasonable & customary" fees, which are significantly lower then her usual fees. She spends an equal amount of time on each incision, and uses the same amount of equipment. The suture tray, additional suture materials, etc., BTW, are NOT reimbursed by the insurance company (noted as "not separately reimbursible" on your EOB by CPT code A4550), so she has to eat that cost in additon to the insurance reduction.

Listen, there is also a method behind the madness of only doing one procedure at a time (even in the same "area") that has to do with a patient's comfort level and healing process.

IMHO, if you are suddenly accusing your "trusted" Physician of being dishonest, you'd be doing this Physician a favor by leaving her practice.

[lealea1005]

I've never heard of a doctor's office or hospital that would give you the CPT codes directly. What has always happened in my experience (and we're talking many, many years of it) is that the doctor's office would resubmit the claims with the correct (or corrected) CPT codes.

Couldn't she just get the CPTs used from her EOB?

[cbg]

I don't see any reason why not. But I also would have been astounded if they had given them to her over the phone.