Question
State: Illinois
I recently had a consultation with a plastic surgeon concerning excisions to remove 3 small scars on my cheek. The surgeon quoted me $200 total for each excision. I had the surgery..was charged the $600 and paid with a check. The doc cashed my check...I thought nothing more about it.
A few months later, I receive a statement from my health insurance co.
It shows the doctors price for each excision as $800!!! ..and he is trying to collect from them $2400!!! ..plus I paid him $600!!!
The statement was itemized and gave me a PPO deductible of about $400.
Is this guy trying to pull a fast one..??? or what?
Is this considered Insurance fraud? ..If so please advise...
Thank you..Kat
Answer
What paperwork do you have from the doctor agreeing to the $200 per excision price?
Gather your paperwork and contact your insurance company in writing explaining that the bill was for $600 and was paid in full. You may want to see about getting copy of the cancelled check from the bank.
Review the doctor's bill for $2400. Do the codes for the procedures match the work that was performed?
If this was going to be a cash procedure, why did the doc have your insurance info? Did you have a prior medical relationship with the doctor?
Answer
If the physician is in-network, you shouldn't be paying him any money up front. That's normally part of their contract agreement. Anything you owe for deductible or co-pay is normally figured out after the fact when they bill your insurance company, and then they normally bill you for what you owe afterwards.
However, if you already paid $600 up front, then when he billed the insurance company, at the very least the HCFA billing should have reflected the $600 already paid. If your deductible was only $400, then he owes you a refund of $200. That's why you never pay up front because getting that money back from them can be like trying to get blood from a stone, depending on the provider.
Random Guy is right; unless you have something in writing from him showing he was only going to charge $200 per procedure, he can technically bill whatever he wants. But at the end of the day, he's only going to get what the PPO contracted rate for those procedures are. Which may be why he's trying to get money out of you up front. To make up the difference.
It sounds suspicious. Gather your info, call your insurance company and ask to speak to their Fraud Investigation Unit (may have different name depending on the company). Explain the situation to them. They may have a file on this provider already, or they may be able to find information on the provider on a network they share with other insurance companies. It at least bears some further looking into.
I'm actually surprised your insurance company covered it. Sounds cosmetic, which most plans don't cover. There's a chance he changed up the ICD-9 and CPT codes and/or the operative report too to get it covered as well.
Answer
If he's an out of network provider, and the procedure is covered by your insurance at the out of network rate, then you should get the reimbursement of $200 directly from the insurance company. It's possible that the rest of the money is for the operating room (if one was used), anesthesia, pathology, supplies, etc, and the removal procedure itself was what the $200 was for. In that case there's nothing shady going on other then the doctor not informing you what the full cost was going to be up front.
I would contact both the doctor's office (speak with the insurance biller, that will be the most knowledgeable person) and your insurance co and try to get some more information.