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Old 12-11-13, 04:27 PM   #26
3alarmer
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...allow me to enlighten you on the vast conspiracy that is today's medical billing.

It's a game, with a reference book and a set of rules, and the insurance companies
play it in order to minimize payouts, the physicians offices play it in order to either
get their claims paid at all, and sometimes to increase their payment on a particular
service that is done on a relatively routine basis.

By all means if you feel this strongly about what happened refer it to"the authorities",
(whoever that might be in your neck of the woods.)

Just do not expect anyone to take you too seriously and you'll be fine.


There is a rule on the internet that also applies here:

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–Rule 0: There is no Cabal.
Which can be interpreted either as “Stop seeing conspiracies around every corner” or
“Even if there was a secret Cabal who controlled this forum/Wikipedia/The Internet, no-one would admit to being on it.”
Edit: Millcreek was faster....what else is new ?
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Old 12-11-13, 04:32 PM   #27
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No but you sure might get a nearly $2000 bill at a time in your life when you can least afford it. If I'd even known about the loophole that lets the insurance company off the hook for it I'd have refused it when my doctor sent me there.

The OP should absolutely do what he or she can about this whether it was intentional or just through incompetence.
So my guess is that you were sent for a screening colonoscopy and it turned into a diagnostic colonoscopy when the provider did a biopsy or removed some polyps; or that you received a level of anesthesia that was not covered by your insurance plan. In either of these situations, the patient can receive a bill that they did not expect.
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Old 12-11-13, 04:34 PM   #28
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...allow me to enlighten you on the vast conspiracy that is today's medical billing.

Edit: Millcreek was faster....what else is new ?
That's what she said!
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Old 12-11-13, 06:06 PM   #29
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I do healthcare risk management for a living. Noting the OPs comments as to a 'head office', this makes me think that he was involved with a larger healthcare system. Every such system has what is a called a 'compliance officer' whose job it is to look into such matters. You can contact that person, often anonymously if you wish, and express your concerns there. They will likely work with the billing and coding people to determine the merits of your concern and if any corrective action or re-training needs to take place. Look on the system's website to see how to contact the compliance officer.

Having said this, medical coding and billing is a rats nest. The insurance companies game the system to try and decrease reimbursement to the providers, and the providers game the system to try and increase the reimbursement. There are often multiple yet entirely ethical and legal ways to code a given encounter or procedure. The choice of any particular one of these multiple ways does not necessarily mean that anything shady is going on. After the provider submits the billing code for a given encounter or procedure, the billing software and/or the billing clerks get their hands on it, and can make all sorts of changes according to the requirements of a given insurance plan or upcoding or downcoding.

Thinking that the office manager or provider is somehow personally profiting from this is very unlikely, unless they are submitting 'ghost claims' for patients, encounters or procedures that never actually happened.
Exactly.
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Old 12-11-13, 09:19 PM   #30
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So my guess is that you were sent for a screening colonoscopy and it turned into a diagnostic colonoscopy when the provider did a biopsy or removed some polyps; or that you received a level of anesthesia that was not covered by your insurance plan. In either of these situations, the patient can receive a bill that they did not expect.
Exactly. They removed 2 polyps (which were benign) and that takes it out of the "preventive care" catagory. It's actually a pretty common thing I've heard and that's how the insurance companies keep their costs in check in a runaway system where there is nothing to keep the medical profession's prices in check through much of any bidding system.

So I don't really blame the insurance companies so much as the runaway system. People talk about "socialism" when they talk about getting the government involved but this isn't really some natural supply and demand kind of system. They've got you by the throat when it comes to the medical profession's profits because you're betting on your life if you refuse the service.

I would've made the bet until I was eligible for medicare though if I'd only known.
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Old 12-11-13, 09:26 PM   #31
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Thinking that the office manager or provider is somehow personally profiting from this is very unlikely, unless they are submitting 'ghost claims' for patients, encounters or procedures that never actually happened.
I tend to agree. That's a little risky and probably doesn't add up to being worth illegal activity. There are enough legal loopholes that insurance companies lobby for to keep their costs in check. But incompetence in the medical profession billing practices is out there because I've heard of other examples elsewhere. So the OP should definitely call them on it for other peoples sake.
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Old 12-11-13, 09:52 PM   #32
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The coding issue is familiar. I just went through the same process with a rabies treatment. I called folks handling our insurance and they told me exactly what the coding input by the hospital should have been, an emergency treatment vs preventative treatment. Had to call the hospital billing folks multiple times and I wasn't sure if they were stupid, incompetant, or apathetic, maybe all three. Proving anything criminal in a system so bizarrely complex would have been a paperwork trail nightmare. I say take your success, be happy, and move on.
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Old 12-11-13, 10:01 PM   #33
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OP, you may have run into an instance of provider fraud. CPT codes are, generally, not all that difficult to figure out, especially for routine procedures.

You shouldn't have had to go all the way to the top in order to get this issue resolved.

OTOH, I seriously doubt that your insurance carrier will do much of anything if you report it to them.

Is this worth your time? Probably not.
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Old 12-11-13, 11:21 PM   #34
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I could just imagine it might be like going to the Better Business Bureau or the Labor Board now that I think about it. Or like complaining to bureaucracies about the shady practices of technical schools who get government grants or anything else like that. Most of these outfits that are supposed to protect the consumer or worker are pretty toothless anyway.

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Old 12-12-13, 06:59 AM   #35
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OP,

You shouldn't have had to go all the way to the top in order to get this issue resolved.
I agree. But the office manager in question sat on his hands and did nothing for 6 weeks after my
initial contact with then home office, even after I had called him 3 weeks or so ago to check on the progress. I was informed that it was in the works and would take a couple of weeks. As no action had apparently occurred, I called the home office again. They determined that the manager had not processed the refund paperwork. My contact at the home office climbed the ladder to get things moving, and I received my check 3 days later.

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OTOH, I seriously doubt that your insurance carrier will do much of anything if you report it to them.

Is this worth your time? Probably not.
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I could just imagine it might be like going to the Better Business Bureau or the Labor Board now that I think about it. Or like complaining to bureaucracies about the shady practices of technical schools who get government grants or anything else like that. Most of these outfits that are supposed to protect the consumer or worker are pretty toothless anyway.
I was thinking more like the action line at one of the area TV stations' news departments. They usually seem to get results.

As my situation has been resolved, maybe it is not in my best interest to pursue this?
However, I cannot help but think of how many other trusting patients they have pulled this on.
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Old 12-12-13, 08:33 AM   #36
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I was thinking more like the action line at one of the area TV stations' news departments. They usually seem to get results.

As my situation has been resolved, maybe it is not in my best interest to pursue this?
However, I cannot help but think of how many other trusting patients they have pulled this on.

If you do this, don't be too surprised to receive a letter firing you from the practice. So you should be certain to first find another practice that accepts your insurance and is taking new patients. Depending on where you are, this may be easy or difficult.

The practice is not obligated to keep seeing you. I fire patients from our practices all the time, for a variety of reasons: scamming us for narcotics, abusive to staff, does not pay the bill, etc. As long as you are not firing them based on a protected class (age, gender, ethnic origin, etc.) and give them 30 days notice, it is perfectly ethical and legal to discharge a patient from your practice.

Healthcare only works when there is a mutual trusting relationship between patient and provider. Here, I have a situation in which the patient clearly does not trust me, and I am not going to be looking over my shoulder all the time wondering when he will file his next complaint. It is better for both of us if I discharge the patient and have him find another practice that better meets his needs.
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Old 12-12-13, 08:37 AM   #37
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If you do this, don't be too surprised to receive a letter firing you from the practice.

Healthcare only works when there is a mutual trusting relationship between patient and provider. Here, I have a situation in which the patient clearly does not trust me, and I am not going to be looking over my shoulder all the time wondering when he will file his next complaint. It is better for both of us if I discharge the patient and have him find another practice that better meets his needs.
Thanks for the advice.
I have already fired them.
Like..........I could still trust THEM ???
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Old 12-12-13, 08:40 AM   #38
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OK. Whatever it was I didn't feel it until I got the bill.
the good drugs help...
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Old 12-12-13, 08:46 AM   #39
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Thanks for the advice.
I have already fired them.
Like..........I could still trust THEM ???
There you go! A win-win for everyone!
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Old 12-12-13, 01:32 PM   #40
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OTOH, I seriously doubt that your insurance carrier will do much of anything if you report it to them.

Is this worth your time? Probably not.
It's pretty ironic that even with the generation of quarterly profits for the shareholders being the main reason for the existence of the insurance companies that they don't take complaints like yours seriously. My father is a bored retired lawyer who got so frustrated with Medicare's inability/unwillingness to correct overcharges they'd paid for that he just quit complaining. I hope you can get better results, but I wouldn't count on it.
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Old 12-12-13, 03:29 PM   #41
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I tend to agree. That's a little risky and probably doesn't add up to being worth illegal activity. There are enough legal loopholes that insurance companies lobby for to keep their costs in check. But incompetence in the medical profession billing practices is out there because I've heard of other examples elsewhere. So the OP should definitely call them on it for other peoples sake.
I think that's illegal now. That is my understanding. There is a -33 modifier which indicated "screening turned to therapeutic" that should have been used.

I guarantee it's not a doctor or office coding error and has nothing to do with fraud. It was a loophole used by insurance companies, and for a while it was even a problem with Medicare. Gasp! Even the Federal government.
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Old 12-12-13, 03:58 PM   #42
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I think that's illegal now. That is my understanding. There is a -33 modifier which indicated "screening turned to therapeutic" that should have been used.

I guarantee it's not a doctor or office coding error and has nothing to do with fraud. It was a loophole used by insurance companies, and for a while it was even a problem with Medicare. Gasp! Even the Federal government.
Well it would be illegal if not just a mistake but I meant that it probably wouldn't be an under the table kickback situation because of the risk, imo. On the other hand it wouldn't really surprise me that much if it were.

As for my situation it's all still legal. When they find a polyp in you, benign or not, it takes it out of the "preventative" category and you'll be stuck with the larger portion of a way overinflated bill with my company's carrier.
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Old 12-12-13, 04:11 PM   #43
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the good drugs help...
Well since there's nothing actually wrong with me I don't get any good drugs and since I'm stuck with $100 a month payments now it's certainly going to cut into any recreational mild drug budget. There are lots of things I need besides a $2000 medical bill and any new Mercian bicycle is now a long gone fantasy.

I'm just glad I've got my '83 road Trek 970 frame before this happened and that will be the extent of my bike collection for a long long time if not for good. I don't suppose I need more than 2 bikes anyway.
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Old 12-12-13, 04:48 PM   #44
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Well it would be illegal if not just a mistake but I meant that it probably wouldn't be an under the table kickback situation because of the risk, imo. On the other hand it wouldn't really surprise me that much if it were.

As for my situation it's all still legal. When they find a polyp in you, benign or not, it takes it out of the "preventative" category and you'll be stuck with the larger portion of a way overinflated bill with my company's carrier.
you really don't know what you're talking about.
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Old 12-12-13, 07:17 PM   #45
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you really don't know what you're talking about.
Well are you telling me that my situation is illegal ? Because that's not my understanding from talking with the person who speaks to our company every year about insurance coverage. And, no, I know very little about these things until I get a bill for nearly $2000 and have to find out about it.

My understanding is that this hasn't really changed under the new federal guidelines either from what she told us. If they find a polyp during a colonoscopy, benign or not, then you could still get stuck with larger portion of the the bill depending on the policy of the carrier. At any rate I had my colonoscopy before the new federal guidelines were in place anyway.

So enlighten me if you know better because I need to know.

And I don't pretend to know what the OPs legal situation is. I'm just saying that the office manager is not likely in cahoots with the insurance company as has been previously suggested.

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Old 12-12-13, 07:49 PM   #46
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Well are you telling me that my situation is illegal ? Because that's not my understanding from talking with the person who speaks to our company every year about insurance coverage. And, no, I know very little about these things until I get a bill for nearly $2000 and have to find out about it.

My understanding is that this hasn't really changed under the new federal guidelines either from what she told us. If they find a polyp during a colonoscopy, benign or not, then you could still get stuck with larger portion of the the bill depending on the policy of the carrier. ...
Based on this site:
http://www.npr.org/blogs/health/2013...ling-kerfuffle
people should not be charged in your situation if their policy is compliant with the new healthcare guidelines. But unfortunately it sounds like the bill you got was legal and not at all uncommon under the existing rules.
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Old 12-12-13, 09:21 PM   #47
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If you do this, don't be too surprised to receive a letter firing you from the practice. So you should be certain to first find another practice that accepts your insurance and is taking new patients. Depending on where you are, this may be easy or difficult.

The practice is not obligated to keep seeing you. I fire patients from our practices all the time, for a variety of reasons: scamming us for narcotics, abusive to staff, does not pay the bill, etc. As long as you are not firing them based on a protected class (age, gender, ethnic origin, etc.) and give them 30 days notice, it is perfectly ethical and legal to discharge a patient from your practice.

Healthcare only works when there is a mutual trusting relationship between patient and provider. Here, I have a situation in which the patient clearly does not trust me, and I am not going to be looking over my shoulder all the time wondering when he will file his next complaint. It is better for both of us if I discharge the patient and have him find another practice that better meets his needs.
I believe he said he already beat them to it in a in a previous post.......as he most certainly should have.
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Old 12-12-13, 09:31 PM   #48
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Based on this site:
http://www.npr.org/blogs/health/2013...ling-kerfuffle
people should not be charged in your situation if their policy is compliant with the new healthcare guidelines. But unfortunately it sounds like the bill you got was legal and not at all uncommon under the existing rules.
OK thanks very much for this

As I gathered, there are loopholes in which I could also still be stuck with the larger part of the bill. And my doctor certainly must be confused about all of this as well since she was of the opinion that medicare would safely bail me out of any responsibility for the bill when I become eligible for it.

I kind of wonder sometimes though if a carriers approval of physicians might rely on how they code these things.

Hmmm......I also wonder how much they charge for a colonoscopy across the Mexican border.
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Old 12-12-13, 10:15 PM   #49
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Hmmm......I also wonder how much they charge for a colonoscopy across the Mexican border.
Thanks- now I'm going to be visualizing that all night...
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Old 12-12-13, 10:59 PM   #50
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...you can save some money on the pre colonoscopy procedure, by just drinking the local tap water.
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