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Does this sound like fraud to you?

mrs.ozmrs.oz member
in 3rd Trimester

When I moved at 7 months pregnant I went to interview an OB in my new state.  I knew I was high risk so I sent my records ahead of time to make sure this OB would take me as a patient.  I was told she would take me.  When I had my appointment I decided to stick with this OB and agreed to the tests she wanted to do.  After I had done blood work and other tests the doctor told me she was going to send me to a consult at the maternal fetal medicine doctor.  HA!  She didn't want to take me as a patient after all. 

This doctor is in my insurance network (the doctor I'm seeing now isn't, but that's a different story).  That means that my maternity care would be covered 100% with $0 deductible.  However, this doctor billed my one and only appointment with her as "pregnancy confirmation".  To my insurance company "pregnancy confirmation" is not the same as appointments for maternity care which is why I was seeing this doctor.  She had my records.  She knew I was 7 months pregnant.  She knew I was there to continue my care, not for her to tell me I'm pregnant.  After talking to the billing people I was told they always bill the first appointment as "pregnancy confirmation" no matter what.  Well, now I owe $150 because of the way they billed the visit.  They refuse to resubmit the bill.  Just because you bill every first visit the same doesn't make it right.

I think it's fraud that they're billing my visit as something it was clearly not.  I could see if they billed it as a maternity new patient visit, but they didn't.  My insurance company won't change the billing, it has to come from the doctor's office.  But like I said, the office refuses to resubmit the billing. 

Would you go to your insurance company and file an investigation or just pay the $150?   

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Re: Does this sound like fraud to you?

  • PurpleK26PurpleK26 member
    Well, I don't know that I'd file an investigation, but I'd at least let them know that this is not what you were there for, they knew you were pg and had submitted incorrect information. The insurance company can decide whether or not they want to pursue further 'action'.
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  • StrawberryAlarmClockStrawberryAlarmClock member
    I would call my insurance co b/c if you're paying $150, they're paying more, too. They won't want to dish out any more money than necessary, either, and they have way more clout than you.
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  • mejumpmore1mejumpmore1
    It depends, what would be the cost to you if it were billed differently? If it would be nothing or significantly less, I would raise he!!. If there would be no difference then I'd let it slide.
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  • Sam78Sam78
    It is not fraud - just because they had your records doesn't mean that they didn't need to confirm that you were still pregnant for themselves.  I would continue to try to work with the doctor's office - ask to speak to the head of the practice instead of the billing person and explain the problem and see if they will work with you.  If not, talk to your insurance company and see if they will do anything (they probably will not, they are hell bent on keeping with the codes submitted by the doctor), otherwise, apply it towards your deductible.
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  • AJflowersAJflowers member
    Um, I think it's rediculous that 1. they won't re-submit for you, I've done ins. before and it's not that big of a deal, 2. you are 7 months pregnant and you were receiving care and moved, and they are ALLOWED to bill an apt as pregnancy confirmation.  I would do something!  Maybe filing for investigation will get the Drs office to step up and re-submit.
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  • erin922erin922 member
    You could try to appeal it with your insurance company.  Or at least ask them what else it could be billed as.  I know that when I switched OB's it was billed at "new patient evaluation".  I don't know if that would change what you owe. 
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  • mrs.ozmrs.oz member

    imagePurpleK26:
    Well, I don't know that I'd file an investigation, but I'd at least let them know that this is not what you were there for, they knew you were pg and had submitted incorrect information. The insurance company can decide whether or not they want to pursue further 'action'.

    I have.  I've talked to the head billing person 3 times today and probably 12 times total.  She says they won't change the billing code. 

    The insurance company says they can't tell the doctor how to bill.  They believe what the doctor files until someone takes action by either the doctor by refiling the claim or me asking for an investigation. 

    If they filed as maternity care then my cost would be $0.

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  • Madison789Madison789

    Do 2 things. Have an investigation done by your insurance company.

    Also, have a lawyer draw up a letter for you alleging fraud, or whatever the lawyer thinks is the appropriate term to use, and have the lawyer send the letter to the head of the practice.  Make sure it is on the lawyer's letterhead paper.  Make sure also that the lawyer mentions that you have filed for an investigation with the insurance company.  That will probably get them to change the billing code.

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  • Sam78Sam78

    Stop talking to the billing person, talk to the head of the practice (or her superior). She has made her position clear, now you need to get the practice to re-evaluate which she does not have the authority to do.

    No lawyer will allege fraud in this case because the elements are not met (ok, maybe a shady lawyer would) not to mention that the cost of the letter will get close to or exceed the $150 you'll be charged for the appointment.

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  • Kelly-reneeKelly-renee

    If they will let you, try asking to leave a message for the OB or NP.  They may be willing to make the billing people change what they're doing in your situation.  I know a friend ended up with a similar situation, not OB related, but it took them about 6 mos before the hospital would change the billing code.  They didn't want to admit that they had made an error.

    Also, ask your insurance company person what they would do if they were in your shoes.  Sometimes just chatting with them for a little bit will get them to give you much better information than when they realize how stressed you are about the situation.

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  • BriellabellaBriellabella member

    Yes, it does sound like fraud. And it happens more than people know at doctors offices, but unfortunately, there isn't much that you can do about it more than you have already done (without costing yourself more aggrievation, etc.)

     

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  • blissfully_caffeinatedblissfully_caffeinated
    I would appeal the claim with your insurance company.
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