Medical Bill Bait & Switch

[SusieTran]

I am disputing a medical charge and the provider has threatened to turn the bill over to a CA.

 

Before the surgery, the doctor's office took my insurance information and let me know the insurance would pay 75% and the remaining 25% I was to pay the day before the surgery. I paid the 25% but afterward, the insurance didn't pay anywhere near 75%. So the doctor's office wants me to pay the remaining amount even though they have admitted that my insurance company has a history of never paying 75%. My thinking is this is a classic 'bait and switch' due to the doctor's office admitting that they knew my insurance wouldn't pay the amount before I ever stepped foot in their office. I think this is considered fraud.

 

What should I do? They will turn it over to CA if I don't pay by 01/15/09.

[Cosmos Human]

What does your EOB state?

 

Your MD can't back bill you for the balance. It is a contract rate between the INS Co and the MD.

 

Call your INS co asap.

 

Often I have a visit...ex: $115, I pay a $10.00 co-pay, the rate the MD gets is $50.00. The balance then can't be billed to the patient.

 

Call your state board of INS to complain if no resolution.

[SusieTran]

The doctor has no agreement/contract with the insurance company-doctor doesn't take insurance. The doctor took my insurance information and informed me what the insurance company would pay. Afterward the doctor's office stated that my insurance company never pays 75% even though they said it would before the surgery.

[cotterpin]

What does your EOB state?

 

Your MD can't back bill you for the balance. It is a contract rate between the INS Co and the MD.

 

Call your INS co asap.

 

Often I have a visit...ex: $115, I pay a $10.00 co-pay, the rate the MD gets is $50.00. The balance then can't be billed to the patient.

 

Call your state board of INS to complain if no resolution.

 

 

 

No, that's not true in all cases. In the OP's case, the MD is not contracted with the insurance, they don't have to abide by the EOB at all. They stated that there rate was X and told the patient their expected amount was 25% of that. No contract means they don't have to accept anything less than payment in full, UNLESS they stated they would accept the insurance payment as payment in full.

 

OP, check your benefits, they probably paid 75% of the rate they would pay a contracted provider or 75% of usual and customary charges, neither of which your MD is required to accept. Check your benefits to see if they pay 75% of charges on out of network bills or if there is something in there stating they only pay 75% of the network rate (or similar terminology) then a quick call to them may get them to pay the extra.

 

The MD's office isn't the problem most likely it is the insurer in this case. It's not bait and switch nor is it fraud, read your paperwork more closely. They did you a favor (as they are non contracted) by billing your insurance (courtesy!) and accepting payment from them at all. They could have made you pay 100% and then made YOU bill your insurer and get reimbursed

[cushiefan]

Why did the insurer pay less than 75% of billed charges? My bet is that the doctor's fee was more than usual, customary and reasonable. I'd remind the dr that you agreed to his services because you were told by his office that you would pay 25% and your insurer would pay 75%. I would ask him to help you appeal to your insurer, to see if the insurer will pay more. His help could include explaining why his fee was usual, customary and reasonable, which is the measure most insurers use to pay for noncontracted services.

[SusieTran]

I'd remind the dr that you agreed to his services because you were told by his office that you would pay 25% and your insurer would pay 75%.

I have done so, yet the doctor's office doesn't care what they said to me beforehand; they want to be paid. Essentially, they admitted they have never gotten 75% out of my insurance company, yet they told me prior to the surgery that my insurance company would pay 75%.

I would ask him to help you appeal to your insurer, to see if the insurer will pay more.

The doctor's office did help me appeal and my insurer paid a few hundred dollars more on a balance that is in the thousands.

 

I would like to somehow prevent this going against my credit record. Does anyone know anything I can do pro-actively? Thanks for everybody's input. It just seems like what the doctor's office is doing is wrong. Any other ideas??

[SusieTran]

Anybody have any ideas?

[cotterpin]

Anybody have any ideas?

 

 

re-appeal to your insurance company

[cushiefan]

Since you went out of network, your health insurer probably won't do any more for you.

 

I'd talk to a lawyer at this point. Do you have a friend or relative who's a lawyer who can send a letter on your behalf without charging you? That might convince the doctor to drop any claim for additional payment.

 

You might also complain to your state's insurance commissioner and board of medical quality assurance, who might be very interested in learning that the office is lying to patients to get them to come into the office. However, that won't protect your credit report.

[SusieTran]

I wanted to give an update to this post so others can learn from it. 

 

As I was researching the law in the state in which this occurred, and continuing to correspond with the office manager, it became clear she was going to initiate collection. However, in our many emails of correspondence, she admitted to (unbeknownst to her) breaking the law. 

 

Subsequently, I sent a letter quoting which statutes were violated, along with proof of her admitting as such, and without reply, she dropped pursuing collection.

 

The violations would have been substantial if I chose to pursue action (which I didn't). 

 

Maybe others can learn from my experience and not get bullied by those who are breaking the law.

 

Thankfully, I didn't have to hire a lawyer.