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Insurance Fraud .. any ideas?
I saw my doctor about 2 weeks ago. He told me to make another appointment for 6 weeks later (in another month or so). I did. Yesterday I got a call from his office telling me that he no longer accepts my insurance but 2 of the 3 other doctors in his office will accept it. Would I like to see one of them? Yes, that's not a problem ... but what if I just paid cash to see this guy? They told me I can't because it would be insurance fraud. How is it insurance fraud if I pay cash and don't involve the insurance company at all? They say it is because I have insurance. ??? They add that I can see any doctor I like but I can't see the doctor I've been seeing because of the insurance fraud thing. More ???? WTF?? Half of me thinks it's just a slick way of saying he doesn't want to see me anymore for whatever reason (it's not like I'm rude to him, miss appointments without calling (or even with calling) or am constantly late). Maybe he thinks it's rude when he says "lose weight" and I haven't done it (it's not exactly easy to do). The other half thinks that there might be something else going on that I don't understand and they don't have the time or inclination to explain. Anyone have any ideas? I have no clue. Jun 06 15 06:06 am Link I think the rule says: You have to commit insurance fraud before you are allowed to know what insurance fraud is. Jun 06 15 07:00 am Link Lovely Day Media wrote: Who knows. Jun 06 15 07:15 am Link Lovely Day Media wrote: Well, from the insurance company's perspective, it does look fishy. By paying in cash, it looks like you are trying to hide a medical condition that might effect your future coverage and/or rates. Jun 06 15 08:57 am Link Could be patient dumping, or perhaps he got into trouble by double-billing where a patient paid but his billing outfit forwarded it to insurance as well. Never know. I got into that mess with some eye doc who I paid for eye exam, and he turned it in as a surgical procedure and all heck broke loose when insurance called me on it. I'd just get another doctor since you are getting the brush off. Some docs just have too many patients and would like to unload some too. Some over prescribe so that issue to downsize their Rx stuff is out there too as insurance seems to be running the show now with all the negotiations BTS too. Jun 06 15 09:07 am Link Lovely Day Media wrote: It sounds like they're handing you a pile of BS. Jun 06 15 09:23 am Link The doctor is probably bound by a contract with the insurance company - if he accepts payments outside the specified copays and such covered by that contract - this is to prevent doctors from collecting amounts over the agreed payment specified by the insurance company for each type of issue. Even if the doctor can no longer do new insurance covered work for you, that contract probably has a tail which would keep him from doing services outside the contract coverage to keep the bad doctors from stopping the contract and then turning around and charging that extra money. If you are covered by a new insurance company, with their own rules that would not be a problem. What you are missing is that in the early days of medicare that sort of billing was too commonly done to skirt around low medicare payments for a particular condition, and was effectively stopped by what was later written into the contract between the doctor and the insurance company. The cash for services rather than insurance is a later development - and is perfectly ok too - but the doctor does have to carefully manage the transition. Think what you are seeing in this case is precisely that carefully managed transition. Jun 06 15 10:09 am Link Why would you want to be someone's patient when they clearly don't want to be your doctor? Jun 06 15 12:20 pm Link It sounded fishy to me, but I am not in that field, so, I asked some people who are. Apparently, it is not unusual for a doctor in an office to refuse insurance that others in the office accept. It is not unusual for doctors to refuse the case payments because of medicare/insurance rules. It strikes me as strange. The people I asked couldn't fully explain it. One is a PT. She said that they notify patients when their insurance coverage is closing in on the maximum, and some patients start paying in cash to keep the healing process going. Yet, it is fraud if the doctor accepts payment for items not covered by insurance or from people outside of the insurance. I gather from what the people told me, that they don't really understand it either, but they know the rules and follow the rules. The reasons, like most things which involve big government or business, are besides the point. Sorry. Jun 06 15 01:00 pm Link Isis22 wrote: For me, doctors aren't easy to come by. Sure, they're everywhere but a doctor I like and trust a little bit doesn't come easily or often. Some people stick with mechanics, hair stylists, nail salons or other professionals. I've been seeing this doctor for a little over 2 years and it took at least a year to develop a rapport (break him in). Jun 06 15 03:28 pm Link |