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  1. #1
    Join Date
    Feb 2015
    Posts
    4

    Default Doctor Billed Health Insurance for More than Agreed, Prepaid Cost of a Procedure

    My question involves insurance law for the state of: California

    I recently had an elective surgery a small part of which qualified for insurance coverage. The doctor required I pay in full in advance, and sign a contract stating I understood this was not a medically insurable procedure. I paid, had the surgery and months later receive a EOB from my provider along with a check from them for a small amount. On the EOB I see that the doctor has submitted a claim for well over 4 times the total amount I paid him.

    Has he committed insurance fraud by not disclosing to them the fact that I paid in advance and paid a prearranged price which was around $20,000 less than the claim amount he submitted to them? The doctor is now demanding I send him the insurance check amount - although we had a signed contract and I paid in full prior to the surgery, is he somehow entitled to this insurance check money I received? I called the Drs. office and the billing person was insistent that it was their money and I need to pay them immediately. Am I unwittingly committing insurance fraud if I cash the insurance check? Any thoughts appreciated, Thank-you!

  2. #2
    Join Date
    Jun 2006
    Location
    Massachusetts
    Posts
    24,440

    Default Re: Doctor Over Billing Insurance for Prepaid Elective Procedure - Fraud or Just Busi

    I'm confused. Was the procedure, or was it not, covered by the insurance? And do you have anything in writing showing how much you paid, and that it was supposed to represent full payment?

  3. #3
    Join Date
    Feb 2015
    Posts
    4

    Default Re: Doctor Over Billing Insurance for Prepaid Elective Procedure - Fraud or Just Busi

    The procedure was a combined septoplasty (which insurance covers) and a rhinoplasty (which is not covered). They are often done together and insurance pays for the coverable part.
    I have a signed contract stating the surgery total dollar amount, that extra charges would only be for X-rays and lab tests and stating that it has been has been paid in full prior to the surgery. I paid by credit card so there is a documented receipt.

    There were no xrays taken and lab tests were billed to me directly by the testing company (and paid in full).

  4. #4
    Join Date
    Jun 2006
    Location
    Massachusetts
    Posts
    24,440

    Default Re: Doctor Over Billing Insurance for Prepaid Elective Procedure - Fraud or Just Busi

    So - when you showed this documentation to the insurance company, what did they say?

  5. #5
    Join Date
    Feb 2015
    Posts
    4

    Default Re: Doctor Over Billing Insurance for Prepaid Elective Procedure - Fraud or Just Busi

    Yesterday I spoke with an initial customer service person who then transferred me on to several billing supervisors regarding why the Dr. had billed them for so much more than what I paid, and what and whom the check they sent me was actually for.

    For nearly an hour they repeatedly asked me the details. In the end they said it was reimbursing me for the covered part of the surgery, because the dr was out of network, then told me to call and straighten it out with the Dr.

    They kept asking me what the surgery total was, if I had it in writing and if I paid in full, which has got me wondering..... Is it legal for a dr. to bill that much more than the prearranged, prepaid amount of his services?

  6. #6
    Join Date
    Jan 2010
    Location
    New Jersey
    Posts
    3,663

    Default Re: Doctor Over Billing Insurance for Prepaid Elective Procedure - Fraud or Just Busi

    What may have happened was the doctor billed you what the insurance company would have paid for a covered surgery.

    Say a particular surgery cost $45,000. The doctor wouldn't get paid $45,000 if he were in network, he would get (say) $20,000 for his service from the insurance company. Maybe your insurance company covered $24,000 for this surgery sending you a payment of $4,000. The question that I don't have is, is the doctor entitled to the $4,000? You would need to read the paperwork that you signed from the doctors office.
    I'm not a lawyer, but I did stay at a Holiday Inn Express last night.......

  7. #7
    Join Date
    Feb 2015
    Posts
    4

    Default Re: Doctor Over Billing Insurance for Prepaid Elective Procedure - Fraud or Just Busi

    The paper work does not address insurance payments at all, it discusses risks, before and after care, etc.
    Regarding costs, it says the patient understands this is an elective procedure, health insurance does not cover this surgery, entire cost of surgery to be paid in full prior to surgery and at the bottom it says date, dollar amount and paid in full.

  8. #8
    Join Date
    Jun 2006
    Location
    Massachusetts
    Posts
    24,440

    Default Re: Doctor Over Billing Insurance for Prepaid Elective Procedure - Fraud or Just Busi

    This is one instance where I don't think you're going to get an answer except by taking ALL the documentation, including a copy of your insurance policy, to an attorney for review.

  9. #9

    Default Re: Doctor Over Billing Insurance for Prepaid Elective Procedure - Fraud or Just Busi

    If the doctor is PPO provider and that is the insurance you have, then they are under contract to accept what THE insurance states.

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