Forums > Off-Topic Discussion > Insurance Fraud .. any ideas?

Photographer

Lovely Day Media

Posts: 5885

Vineland, New Jersey, US

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

Photographer

Evan Hiltunen

Posts: 4162

Minneapolis, Minnesota, US

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

Model

Jules NYC

Posts: 21617

New York, New York, US

Lovely Day Media wrote:
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.

Who knows.

Why don't you find a doctor that inspires you to lose weight.
Wait a second, why don't YOU find some inspiration to lose weight.

Not being harsh here.  I just remember you mentioning in a thread how much you weighed and it's dangerous to YOU. I doubt a doctor would refuse you as a patient because you didn't do 'as he says'.  Do you know how many doctors/nurses smoke?  That really gets me, esp. when they're smoking outside the building like a truant teenager.

Get another doctor.  If you see someone within the same office your medical records are reviewed just the same.  With your consent your records can be sent elsewhere.

Jun 06 15 07:15 am Link

Photographer

Looknsee Photography

Posts: 26342

Portland, Oregon, US

Lovely Day Media wrote:
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??

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.

But what do I know?

Jun 06 15 08:57 am Link

Clothing Designer

GRMACK

Posts: 5436

Bakersfield, California, US

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

Photographer

Lightcraft Studio

Posts: 13682

Las Vegas, Nevada, US

Lovely Day Media wrote:
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?

It sounds like they're handing you a pile of BS.

You can Google "direct-pay doctors" to read about the current trend toward cash-only medical services. That's becoming part of the landscape nowadays. Maybe this particular doctor got into trouble with the IRS or something and is on a tight leash regarding cash payments, who knows.

Jun 06 15 09:23 am Link

Photographer

Btfineart

Posts: 69

Philadelphia, Pennsylvania, US

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

Model

Isis22

Posts: 3557

Muncie, Indiana, US

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

Artist/Painter

Hunter GWPB

Posts: 8155

King of Prussia, Pennsylvania, US

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

Photographer

Lovely Day Media

Posts: 5885

Vineland, New Jersey, US

Isis22 wrote:
Why would you want to be someone's patient when they clearly don't want to be your doctor?

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).

Some have said I'm crazy but I am one who doesn't mind asking personal questions. It's not because I'm being nosy or want to dig up dirt on anyone. It's because I want to know that this person (whoever I'm dealing with) is human and will treat me as such. They don't have to tell me anything but it's going to be harder for me to trust them if they don't. I'm not asking where they live, how much money they make or what their personal email address is but I do tend to ask them if either of their parents are doctors (in this case).

This is mainly to establish why they are a doctor. I find that most of the time the answer is no, btw. If they want me to share my life with them, I think they should be willing to share a small part of theirs, too.

I also asked because I wasn't 100% clear that he doesn't want to be my doctor. It may be crystal clear to others here but I didn't want to believe that. There is/could be some underlying reason for their actions. I just had no clue what they could be so I asked as someone else may work in the industry, know someone who does or has had prior experiences that were similar.

Jun 06 15 03:28 pm Link