Screwing my health insurance company

[mikester]

Okay,

so My wife's pregnant with our first; she's what they consider an "older mother" which makes them want to run all these tests. We did the minimum except for the Cystic Fibrosis test since it was just a blood test. She came up positive so I had to get tested too.

I go through my Primary Care Physician so that my HMO will pay it 100%. I had the option to pay cash though which would have been $495. Pay attention, my cash price was quoted at $495.

Mistakenly the lab bills my insurance under my PPO options and I get the breakdown of the bill. The total is $2575.00 and my portion is $895.27.

If I had paid cash it would have been $495 out the door.

Why in the world would my evil insurance company have to pay 5 times more than my cash price?

It kind of seems a bit like fraud to me.

[Moses]

Something wrong in Denmark! Either an error or fraud. If you want, scan in the EOB and I'll tell you what's up. I'm certain that's not the normal claim for CF testing!

[mikester]

I'll have to scan it when I get home.

[RickM]

Keep your eyes open right up through the birth. Especially at the hospital.

When my wife had our daughter I was allowed in with a camcorder. I pretty much got the rated G stuff, including all the cheefull doctors and nurses...a great buch of people.

Fast Forward a couple of months: Recieve a bill from an unknown doctor...Hmmm. The bill is for $500 and is for emergency resuscitation of our daughter at birth. ???????? Funny, I don't recall this service.

So my wife calls the doc, figuring it was a simple error, and inquires. First they say that the doctor was in the room to assist if needed. My wife disputes that he was there....they insist. Wife calls back again and says she has a tape of the entire event and he is not there....they counter with "the doctor was on call in the hospital in case something happened". They expected us to pay.

So here we are with a bill from a doctor we never told about, saw or received services from.

Think I paid?

[mikester]

I'm not happy with this situation. I don't like that my insurance company is being billed 5x more than I would pay cash. I think insurance companies suck as much as the next guy but the charges of this lab for this service seems like a scam itself.

If they are charging so much becuase they have to go through the insurance company then they should itemize the bill as such with a line item labeled "Insurance company processing fee."

At least then it would be honest instead of falsely inflating the price of the services rendered.

[TSNAPCRACKLEPOP]

generally, hospitals are rarely requested to provide the actual medical records to adjusters or ins co reps to recieve reimbursement from ins cos.
Ufortunately, individual practitioners are deluged with these requests, and there is no reimbursement till the records are in, and then the reimbursements are SLASHED!!! PLUS, THEY ARRIVE IN THE NEXT BILLING CYCLE, WHICH DELAYS PAYMENT FURTHER, IN A TAKE-IT-OR-LEAVE-IT, FASHION (YES, I AM YELLING!!!)

back to work.

[mikester]

Found this...

http://www.insurance.ca.gov/CSD/Brochure/Other_topics/Fraud.htm

[LeeH]

I went to the dentist today to get a broken composite filling repaired. I hate novacane and for years have had dental work done with just nitrous.

When the procedure was done they bill me for the nitrous. What? Insurance covers novacane, but NOT nitrous. Do I get any credit for NOT getting novacane? Nope! The dentist bills the insurance company for the restoration as an entire procedure... in other words, they get paid for novacane even though they didn't administer it. It just doesn't seem right.

[john70t]

There was an artical the other day about a lack of new dentists and new doctors for the next generation because of those problems and more.
It seems that right now the system isn't broken enough to fix it(difficult to imagine), or the US is in a stuck-on-stupid mode.

[mikester]

Okay, I forgot to scan the thing but I will do it tonight...

Now for the latest update:

I called the lab to tell them to bill through my Primare Car Physician - they said okay (yesterday). So I get a call from them today saying my PCP wouldn't authorize it. So I call the PCP and talk to the Lab tech who did it all and he stated that he couldn't authorize it (even though the Dr had already) because he didn't have any "reason" to do the diagnostic and that I had already started the PPO process by going to the genetic counselor who was out of network.

Well, the facts - I didn't go to the Genetic counselor - my wife did and it's in network for her. She's pregnant and positive for CF so I needed to be tested to see what was going to be up with the baby (not that it would have mattered). That was the reason discussed with the Dr and approved by the Dr so put that on the retro authorization form and bill it through you and my HMO. Lab tech says okay....I call the lab to tell them to call me if there are any problems. I email the Dr to tell her what's going on...then I call Blue Cross and make sure everything I have so far is correct and they confirm it.

All seems okay now but I do think they are victim and once the please pay is directed away from me I'll call their fruad hotline.

[mikester]

Okay, here's the bill...



I emailed the Dr directly and was less than satisfied with her response.

When ever my wife goes to see her it seems like she drops everything but whenever I go I end up waiting for at least a half hour or more in the treating (?) room (not the waiting room). I understand that Dr.s are busy and have been understanding up until this point but now I'm just irritated and ready to look for a new Doc.

Let me know what you think almighty moses...

[Moses]

Bizarre.

You have six charges on the same day with no CPT codes associated with the charges. How can you tell which is which?

Before I would pay, I would ask the doc for a copy of the HCFA bill the doc submitted to the insurance company. I can't imagine an insurance company authorizing payment higher than the cash price.

I hate to suggest it, but it might be creative billing. Perhaps billing for genetic counselling and testing with a combined code.

Something is clearly not right.

[mikester]

What are CPT codes?

When I balked at the dollar amount I was left reponsible for after the improper billing the lab agreed to bring my amount down to the original cash price via "discounts." They have been very helpful in the matter but the invoice still doesn't jive.

Thanks for taking a look at it - given how hard it is to get through to my Dr about it or anyone at that office in general who doesn't want to have me call someone else I think the only option I have is to call Blue Cross's fraud line. I don't much care for helping out an HMO as normally they are the bad folk but I have read instances where it goes both ways.

I read a CBS report on Dr seminars where they have consultants come in and tell them how to "work the system" to bill insurance for maximum payout. Capitalism at its finest but they also reported how some Doctors would not give prime appointment times to low end insurance holders and things like that.

The whole business leave a bad taste in my mouth at times.

[TSNAPCRACKLEPOP]

usually, in a large office, the doctor has no clue, and no time to keep up on the constant billing changes. the person you should speak with is the head of billing for that office. many offices now use clearing houses that bill in their own creative way. take a peek at the medicare bulletins on reimbursement that are sent out weekly via internet for a small sample of how this A.M.A. OWNED HICFA billing fiasco works.

there is an amount, like 20% discount, that is allowed for reduced fees for cash, and that is the reduction in not having to file the claim thru an office, the expense of doing so. A greater discount is considered a dual fee schedule, and is generally illegal.