Something fishy about this - medical fraud?

syrima

Sun, Oct 18 2015, 10:54 pm

A relative went to an ENT due to mild hearing loss. The ENT found there was some cotton in her ears, and used a sort of suction to remove it. This took minutes.
She received a bill for ear surgery totaling over $1000.
This sounds very fishy to me. Should she talk to the doctor first or just call the insurance fraud hotline? Confused

ra_mom

Sun, Oct 18 2015, 11:36 pm

Specialists charge a fortune and get it.
We were charged $1100 6 or so years ago for a 30 second procedure by a plastic surgeon to remove an earring that was stuck in the ear lobe or our child...

happyfaces

Mon, Oct 19 2015, 12:43 am

ra_mom wrote:

Specialists charge a fortune and get it.
We were charged $1100 6 or so years ago for a 30 second procedure by a plastic surgeon to remove an earring that was stuck in the ear lobe or our child...

That's high way robbery!!! May I ask why you went to a plastic surgeon? Just had this with my dd our pediatric took it out for her. Otoh a plastic surgeon will charge you that amount for any visit.

ra_mom

Mon, Oct 19 2015, 1:12 am

happyfaces wrote:

That's high way robbery!!! May I ask why you went to a plastic surgeon? Just had this with my dd our pediatric took it out for her. Otoh a plastic surgeon will charge you that amount for any visit.

Of course it is!
We went to the pediatrician, and he was having a hard time removing it. He told me he could remove it with some pain to dd or he could call the plastic surgeon on duty at the hospital, who takes our insurance, and it would take much quicker. Since I was told he accepted our insurance, I headed to the hospital, paid the $50 co-pay and then headed home.
We were shocked to receive an $1100 bill. Our insurance company sent us a check for half the amount so we could pay the out of network doctor. We should have negotiated on the price being charged by the doctor, but they were threatening reporting to the credit agencies and we were overwhelmed, so we just paid the other half...

Amarante

Mon, Oct 19 2015, 8:22 am

ra_mom wrote:

When you visit a doctor through the ER, the charges are generally higher than for an office visit.

And there is also a huge problem now because a hospital can be in network but the doctors practicing in the ER are not in the network. There is a bill in California which is trying to fix this loophole by requiring that any medical personnel at a hospital be part of the same networks as the hospital.

Last edited by Amarante on Mon, Oct 19 2015, 10:03 am; edited 1 time in total

cnc

Mon, Oct 19 2015, 9:39 am

Amarante wrote:

When you visit a doctor through the ER, the charges are generally higher than for an office visit.

And there is also a huge problem now because a hospital can be in network but the doctors practicing in the ER are not in the network. There is a bill in California which is thing to fix this loophole by requiring that any medical personnel at a hospital be part of the same networks as the hospital.

Not necessarily.
A local plastic surgeon does not accept many insurances in his office but WILL accept them if you meet him at the ER.

Amarante

Mon, Oct 19 2015, 9:45 am

cnc wrote:

Not necessarily.
A local plastic surgeon does not accept many insurances in his office but WILL accept them if you meet him at the ER.

cnc wrote:

Not necessarily.
A local plastic surgeon does not accept many insurances in his office but WILL accept them if you meet him at the ER.

Of course it depends on the doctor and specific billing practices. However,it was widely reported as an issue when patients are charged high amounts because doctors in ER are not in the network

http://www.npr.org/sections/he.....-isnt

http://www.nytimes.com/2014/09......html

http://touch.latimes.com/#sect.....9381/

happybeingamom

Mon, Oct 19 2015, 10:00 am

I have had this issue. Check your insurance company because many if you went to a participating hospital and they assigned you a doctor the insurance company will pay the out of network rate but you will have to file an appeal (they just don't give it even though it is their policy). If you are in the time frame file an appeal to get the money back.

sky

Mon, Oct 19 2015, 10:03 am

Amarante wrote:

When you visit a doctor through the ER, the charges are generally higher than for an office visit.

And there is also a huge problem now because a hospital can be in network but the doctors practicing in the ER are not in the network. There is a bill in California which is thing to fix this loophole by requiring that any medical personnel at a hospital be part of the same networks as the hospital.

I had this. I was in an in network hospital, using an in network OB for my first delivery.
when I was rushed into my emergency C-section the anesthesiologist brought in to assist was out of network. My bill was a whopper. Health insurance suggested I should have asked when he was brought it. considering I was going shaking and freaking out, and in a tremendous amount of pain and couldn't really communicate didn't seem to make a difference to the first women I spoke to. In the end after a lot of phone calls they did cover it.

flmommy

Mon, Oct 19 2015, 11:02 am

Check your receipt or bill or call the office and ask what procedure code your relative was billed for. Once you have the code google it and see what they were billed for. I once was billed for a code they basically said "hour long medically complex visit" for a 2 minute visit where the doctor looked at my son and said literally, "no big deal." When I received a huge bill I wrote the billing office a letter nicely telling them I thought they had made an error that my sons visit was not an hour or medically complex and they must have accidentally used the wrong code could they please re-look over his medical chart and correct and send me a new bill. It worked!

ra_mom

Mon, Oct 19 2015, 6:27 pm

cnc wrote:

Not necessarily.
A local plastic surgeon does not accept many insurances in his office but WILL accept them if you meet him at the ER.

Not this one. We should have negotiated with him. Our pediatrician asked him over the phone if he accepted our insurance and he confirmed before we went over. Lesson learned.
When we needed a plastic surgeon years later, and he and another doctor were available for the emergency, we didn't take him because we didn't trust his billing practices.

nywife

Mon, Oct 19 2015, 8:41 pm

Medical coder here.
A. She should not report the practice before investigating. It's not fair to them.
B. Some procedures seem very silly or easy to the untrained eye but in fact are not. She may not be aware of all the components of what was done and is just inferring that it was "nothing".
C. Most claims are coded with an E&M code in addition to any procedures that were performed. Those can add up quickly.
D. It is her right as a patient to receive a full explanation of benefits and charges. She should have received an EOB from her insurance company, but if not she should call the office and request it.