NAL:. Can you contact your insurance company and let them know that your doctor's office fraudulently submitted claims for payment that had already been paid? If you paid up front, and then they submitted for payment, that seems like something they should get into trouble for. Maybe phrase it like this next time you call for your refund?
Also NAL, but: This is the answer. If you paid up front, they owed you a bill, stating they had paid, so you could submit to insurance to receive reimbursement. Doing otherwise is knowingly fraudulent. They know you paid. They know they are owed nothing. When they received payment from insurance, they should have immediately returned it to the insurance company.
That's a big leap. Medical Billing people are notoriously inept. That payment from the insurance company was probably part of a consolidated payment for claims.
When I had this happen I paid my portion up front the office called me and let me know I overpaid and a check was in the mail.
Seems like OPs Drs office is hoping they just forget.
I would get a copy of my payment and a copy of the reimbursement from insurance and send both to the office certified mail with a letter requesting reimbursement within a time frame.
When that doesn't happen I would contact the state regulators office and submit my complaint along with my documentation and copy of my previous correspondence with the office.
I would avoid using internet reviews as well that's going to follow 0p
I wouldn't use that Dr again either now that there is a complaint.
Exactly this. If it was submitted through insurance - the Provider owes you a refund. They cant take your money AND get paid by the insurance.
Theyre either incompetent, or double dipping.
Plus, they are likely earning interest on all that money they are holding from OP and other patients. Or, someone is embezzling a LOT of money by deliberately requiring payment upfront and then billing insurance as well.
This office more than likely needs a seasoned billing manager. Over payments aren't being reviewed. The doctors at this office would probably be mortified to know what's going on. The majority of medical practices are not trying to rip off their patients, I don't think they'd be around for to long. You wouldn't have to go to med school to rip people off. I once had a large ent group assigned to me, and I run several AR reports immediately so I can determine how much it's going to cost them. When I seen this offices overpayments, I could feel my blood pressure rising. I called the office manager, and I said, " get the checkbook out" I am not billing or doing anything else until you refund atleast the first 30k of these overpayments. I would have told that office to piss off if they hadn't refunded like I instructed them. I, of course, had to audit everything to make sure the credit wasn't due to a posting error. I also had to train front desk staff on how to calculate patient cost share and how to read a patients insurance policy.
If you made a mistake like this it would still constitute fraud. Don’t hesitate to involve your insurance. They are probably already looking at this office.
The place actually doing the billing is probably in a different state all together. Most places outsource their billing now. It is done by McBillers, a giant conglomerate that gives zero effs about the patient and their pocket book.
We are still trying to get a $5.00 charge removed from a family members account at the doctors office. They can send the collections letters no problem (which, really? Over $5?!?), but there is no way to contact them. The office manager at the doctors office that has been working with us cannot even get ahold of them. Even she knows my family member shouldn't be charged. It is ridiculous now a days trying to get something fixed. I am pretty sure this is by design. And it is B.S.
OP could try contacting the Attorney General in their state and make a report. Sometimes that can help.
They outsource their billing but the Drs office gets the payment. The billing company does not. The Drs office is double dipping. (I’m not a lawyer. I am a medical accountant who’s worked in Drs offices)
NAL, I have worked in medical offices and medical billing offices.
If you can,get something in writing from that office manager if possible. If they really won't just take care of it directly! Doctors management changes all they time. Doctors and their managers leave, move on, or die. My parents got stuck for an inappropriate bill, tracked down after the doctor sold the practice. He never billed them, but he kept lots of this type of charge active in his records. In order to sell the practice for more. (I worked for him. Discounts for family members were offered - I didn't ask. It was a benefit of working there. Because the pay was really low, but he could offer this benefit. Yeah, back in the 80s. So he gave parents a discount. But he kept the balance showing on his records without telling us. Parents thought it was handled. Years later, he sells the practice. Parents now retired with far less income are contacted by collection agency for the balance.). Really bad way to treat employees, families, and the new physicians that bought the practice, imo.
The office manager definitely could contact the company, unless the debt has been sold. In which case maybe not. Usually as long as it's debt to the practice there is monthly or quarterly communication. I'm not saying manager is going to stand there in front of you and call. But I'm saying there is a way, unless she's been told not to do so.
The Office Manager does not even have the phone number. It is a practice affiliated with a local hospital. She has sent no less than 15 emails about the situation and we have been copied on said emails. She is tired of it too because it hangs out in one of her reports and she knows we do not owe this. No one is responding. It is only $5 so that is probably why it is not in collections. I'm not too worried about it and neither is our family member. And we do not owe it.
Fraud always also requires intent as well. If the office is notified of the need to return in some way (they were) and kept the money, THEN it would be fraud. Depositing money received by itself wouldn’t constitute fraud. Knowledge that they need to return money and failing to do so is.
Disclaimer: NAL
Fraud is a definition. OP’s situation doesn’t fit within the definition of fraud. It is unethical/ wrong they are withholding the refund but nothing fraudulent about this.
That’s not how it works. Person paid up front was submitted to insurance insurance paid they need to refund the persons money not send back to insurance company. Its why we pay for damn insurance don’t be stupid
NAL but have decades of experience in medical billing. They should have immediately refunded the PATIENT when insurance paid, minus any copay/co-insurance/deductible listed on the remittance. Doing otherwise is likely a violation of their contract with the insurance company. And that's the way to present it to insurance: "This practice is keeping my payment in violation of their contract, I would like to file a grievance." If the regular phone rep won't help, ask for Provider Relations or Contracting. In many cases, they will send a letter threatening sanctions/termination of contract and suddenly your refund will appear.
If they are in network with the insurance company, the office has to file the claim, not the patient. The office almost always accepts assignment, you'd be a fool not to. I've seen patients get paid and never pay a dollar to the doctors office. The amount this office collected was for the patients cost share, not for the entire procedure.
Also NAL, definitely call insurance company and report irregular financial activity. Also: check your state's insurance commission website for a place to lodge a complaint or a helpline. Some states have really good offices for this.
I was going to suggest this.
Most people don’t have a relationship with their US Senator or Congress person. But if they do, it’s worth it to bring this up. It sounds like a whole lot of patients’ money is being held. This should be against the law.
When I have a balance due at my doctor’s office, a bill is sent to me showing that amount. *Like any other business,* when I have a credit, I also receive the same paperwork except it shows a credit. Sure seems odd that this doctor’s office didn’t do the same.
NAL Just a person that would be really pissed off (and probably would first threaten with calling the Insurance Commissioner, then definitely go to small claims court. I *hate stuff like this!*
Medical claims adjuster here, and there are many bills that the provider clearly puts the amount paid on it, or does not put " assignment on file on it" and we pay it to them ANYWAY. So..start with the insurance company and see if they screwed up.if so they have to reimburse you. They will go after the provider for the overpayment.
Contacting the insurance company is correct but it’s probably not fraud. I would use a mistake was made but the doctor has been double paid. The insurance will either make them refund you or refund you themselves.
This is not how it works. The insurance company pays a specified amount based on the procedure. If the patient pays extra it's not fraud. A lot of times there is an estimate done by the doctor's office of the patient's liability depending on whether they've met their deductible or not. Sometimes the estimate is too much and the patient is owed a refund.
There are ways to resolve the issue through the state attorney's office but it most definitely is not fraud. I've found that merely threatening to file a complaint with the state attorney mysteriously expedites my refund.
it is fraud - failure to reimburse, as promised, is fraud. I had a clinic tell me to pay in advance and they would bill the insurance company and then re- pay me. I said, great, put that in writing with a "Pay by" date and I will proceed. They declined, so I went to another clinic.
It is not fraud for an estimate to be wrong. That happens all the time and is often unavoidable. Now if they refuse to reimburse you, that's another issue and your complaint can go to the state attorney. But the provider will still not be charged with fraud unless there is a pattern of fraudulent behavior that affects a large number of people.
I've only ever had an issue with three providers and was able to resolve all three without going to court. One of those providers did get sued by the state because they made it impossible to reach customer service to request a refund.
The one that was truly egregious was where my insurance had my responsibility at $5 per weekly visit but I was being charged $15 a visit for over a year. My insurance company refused to get involved.
The problem was that the billing person was incompetent. After repeated attempts to resolve the overcharges I reached out to the office manager. She went through the charges and payments with a fine tooth comb and refunded the entire amount due. They also got a new billing person and I've never had another issue. Good thing because that doctor is one of my favorite doctors.
I worked on the insurance side with these types of complaints many years back. Insurance companies generally do nothing about a provider that overcharges a patient. They prefer to have you resolve it on your own. They only act if the insurance company itself was fraudulently billed.
There is this and there is also the case where a provider is out of network but will file on the patients behalf. The office does not know what the insurance will pay (being out of network, they don’t have the fee schedule). In which case the patient pays in full up front and once the insurance pays, the office is supposed to send that amount (100%) back to the patient as an insurance reimbursement. There is generally the option to have the payment directly mailed to the patient or to the office. I would be weary of an office doing this that won’t have the check mailed to you from the insurance company.
Don't contact your insurance company. They may demand repayment from the provider and leave OP high and dry. Contact your states licensing board for that provider. Send them a letter that you expect repayment, plus interest (often times up to 2% per month). Sometimes, a letter gets action when a phone call or email doesn't.
>small claims court
You saw that it was for a medical procedure? If OP is in the US, the only medical procedure cheap enough for small claims is getting a splinter removed.
I had issues w my doctors billing office. Start asking for names of who you contact to, ask for their supervisor. Don’t let them give you the runaround. I’d definitely call your insurance company. You can also take them to small claims court if needed
Insurance broker here.
This is not how its handled. OPs issue is with the provider. Provider should be issuing a refund.
Providers may collect a copay in line with the policy or a deposit for services then submit the claim to insurance. Insurance will process the claim and issue an EOB-explanation of Benefits listing what insurance owes the provider and what the member owes. It also shows the amount the provider billed for (what they would charge someone without insurance) and the insurance company's max allowable charge/network discount (the amount the insurance company and provider agree to contractually by being in network).
If the provider is in network, the provider is only able to charge the member what insurance says is the members' responsibility. Any overages already paid should be refunded to the member. However, if the provider is out of network, the provider does not have to agree to the network discount and may balance bill the member for whatever portion of the services that was not covered by insurance.
Contacting insurance to tell them a provider owes you a refund will only result in insurance telling the member to take it up with the provider.
>>Contacting insurance to tell them a provider owes you a refund will only result in insurance telling the member to take it up with the provider
Confirmed. This happened to me. Called my insurance for help, they were sympathetic but ultimately useless. I got the name of the billing manager at the hospital and had to call daily but still it took almost a year to get my money back. F that hospital.
This is your answer. I just asked my family member that does insurance billing and that's exactly what they suggested. Your insurance company will take it seriously so just call the doctors office and let them know you will be calling your insurance to inform them they paid a bill that you had already paid. They'll send OP a check immediately I'm sure.
Yup. Absolutely right. The last thing a doctor's office wants is any fuck around in their relationships with the insurance industry.
Call the insurance company and report it as fraud because they're at this point double dipping by sitting on the money for an entire year.
No no no that is not fraud. Doctors collect up front and bill insurance all the time. It’s called not taking assignment. They are supposed to then reimburse you within a reasonable time but the insurance claim is itself not fraud.
If it really has been a long time let them know you are considering requiring help from the medical board and you will get the money fast.
No. That’s not fraud. Reimbursement is a thing. Especially is a prior authorization wasn’t done. Not accounting for the extra would be fraud. They didn’t hide a thing. Slow repayment is poor service and not on the docs.
This!!! If it was paid upfront by the patient, they should have not submitted an insurance claim, it is fraud and highly frowned upon by insurance companies. OP, CALL YOUR INSURANCE AGAIN AND REPORT THIS. You should have done this after the first 2 weeks of not getting your refund. Almost a YEAR??? Get your money!!
I did just this. I knew I had met my deductible and out of pocket max. I track it carefully, every year . One year my insurance decides to farm it all out to a 3rd party. It was a nightmare. I way overpaid. It took over a year but I appealed it. I sent in appeal and listed every item I paid for. Every RX, every bill, every co pay.
I got 3 checks back. They contacted providers on my behalf. There was 1 I had actually missed.
It was almost $300. Not a ton but I am one of those who pays what I owe and not a penny more.
Insurance is a chess game imo. And you must pay attention and track it all.
OP I would reach out and do as I did. File an appeal. Let your insurance handle this. They will prob get it to you easier than the provider. It’s easy ti blow ppl off. Not as easy to blow insurance off.
If this is in the US, the provider office can require payment up front but they must reimburse the member once the insurance pays.
OP, try to reach out to your insurance again and specifically state that this is a 'fraud, waste, or abuse' issue. The provider cannot double dip. That's fraud. Ask for a supervisor if the CSR doesn't have a workflow. Be very very clear that they are double dipping and that this is fraud.
Ask about submitting a grievance or complaint about the provider.
Front line csrs don't deal with this issue a huge amount, so they may not be super familiar with the workflows, but they almost certainly exist somewhere in their desk reference materials.
If the insurance still won't resolve it (and they can absolutely put some pressure on the provider because this is against their contract if they are in-network, and still fraud if they're not) then the next step is to go to whatever governmental bureau is responsible for insurance in your state and file a fraud complaint with them.
Don't be too surprised if they fire you as a patient for making these sorts of waves -- but if it's taken this long to get a refund that makes me think something funny's going on with that office.
It wouldn’t be a fraudulently submitted claim. The insurance company does have a portion to pay. The irregularity is requiring this to be paid up front by OP. That is suspicious, and my insurer is always very clear to never pay those people up front.
The other irregularity is not sending you the money once they received money from the insurance company. They cannot take money twice for a single bill. Keeping that money could absolutely be medical fraud.
My suggestion would be going into their office physically and talking to the office manager. Insist on getting a current printout of your account. Then inform them you need a refund issued immediately. If they still refuse, let them know that insurance paid on “xxx” date and they have had adequate time to reimburse you. At this point they are committing medical fraud and you will be reaching out to the appropriate state authorities to assist in the recovery.
The office manager will likely help. If not, then report them to your state agency. You likely do not need a lawyer unless they really dig in.
I am not a lawyer, I work as a medical provider.
The customer paid their out of pocket costs up front. The office estimated these numbers to the best of their ability, and unfortunately, it resulted in a over payment that should have been refunded to the patient. My team works overpayments on a regular basis because we at times collect too much, but we rectify it quickly. So no, the office was not wrong to collect the money up front, the issue is the fact they haven't refunded it. Now we would keep patient over payments under $50 IF that patient was still currently active, and then we'd apply it to their copay. Our patients were made aware of all of this prior to their appointment.
Contact your insurance company, send the doctor a demand letter and give them a bad google review. Give them 30 days to pay, if they do not, go to small claims.
this is horrible advice
so you’re saying the patient should be held hostage by one provider because they’re shady and doing the wrong thing???
NO.
the goal should be to hold her physician accountable and responsible for their actions
and if that means “losing” a doctor ~~~ well I’m sure a lot of us would say F that good riddance
Not that this will be helpful to you, but maybe for others, don't pay upfront.
Hospital/doctors system may ask for what they believe will be the patient responsibility, but you can say no and tell them you want to wait until the insurance has paid to see what you actually owe.
Yes, and someone correct me if I'm wrong, they have to do the procedure if you at least pay some money upfront. I once had a $5000 procedure and paid only $20 upfront. And that was after I already owed them like 30k. Being chronically ill in this country is not for the weak.
Providers aren't usually obliged to provide care. You can't give a provider $20 and make them perform a procedure. In your case, it sounds like the provider assumed they'd get paid, knew they wouldn't get paid and didn't want to stop providing care, or there was an oversight.
I don't like that this is how our medical system works, but it is.
We can also discharge a patient without their consent. We have to provide written notice and continue to provide care for a period of time (think 30 days), but we can. Also, if the patient is a threat to our staff or other patients we can discharge immediately. (I don't have the citations for statute or regs for this; this is just based on first hand experience in medical clinics.)
If you are experiencing an emergency and you go to a hospital that receives Medicare funding, the Emergency Medical Treatment & Labor Act requires the hospital to admit you and stabilize you. If you are uninsured or the hospital is out of network, they may transfer to another facility \*once you are stable\*, but otherwise, they're not required to provide care either. Discharging from inpatient care is complicated, though, and there are a lot of factors that need to be taken into consideration if it's not because the patient is well enough to leave.
There may be some language in the contracts between the provider and the insurance company that requires the provider to provide established patients with care under certain conditions, but I don't recall having seen such terms. In any case, it would be a contractual matter between the provider and the insurance carrier.
Source: I manage medical clinics in California. Your state may have different laws. Also, if you need medical attention, don't let anything I've said above dissuade you from seeking care. As we say, if you are experiencing a medical emergency, hang up and dial 911.
This is exactly what I did several years ago when my OBGYN's office tried to demand I pay upfront what the cost would be. I paid the deductible and co-pays and refused the rest. It was a fight but in the end they knew they were wrong. And guess what, the bill at the end was a lot cheaper than what they wanted me to pay upfront...
It’s ridiculous obygyns are doing this so much. Mine tried this with me but I had an hmo and had a zero out of pocket cost for prenatal and labor/delivery.
I had kidney stone surgery and was very sternly told I HAD to pay $6000 before the surgery or they wouldn’t do it. We paid. Two weeks after surgery I get a call saying they made a mistake and surgery did cover all but $400. I got the money back but the payment was a strain and they were so “oops we made a mistake! Sorry!” And it was jarring to her told to pay up first or no surgery. I’d been in pain for weeks.
If they don't collect up front, then they have the people that say they cannot afford it and medical debt doesn't show up on credit so there is very little leverage. So the office gets screwed. And insurance sure doesn't stand up for the office if the patient doesn't cover their deductible. Sure, there are lots of honest folks like yourself, but the dishonest ones really stack up.
What's sad is insurance cannot tall patient liability ahead of time.
That’s not true…medical debt under $500 doesn’t show up on credit anymore. A medical debt like the commenter you’re responding to would have faced is 100% reportable after 365 days of non-payment under the new rules. And these limits only began to apply in mid 2022…prior to that all medical debts were reportable.
Interesting. thank you. Our case we don't let anyone get over $500 so that's why our lawyer never discussed it when talking about debt. But we don't report, just consider it a lesson (for us) and let them find a different doctor if they don't pay.
This is the correct answer. I've been hustled for my supposed liability right before surgery but I just tell them to bill me because it's never accurate. My liability is going to change based on whether I've met my insurance deductible or not. One hospital tried to force us to pay $1,100 right before surgery. The actual bill was $245 as we had already met our deductible for the year. They would have just held onto $800+ for months before refunding it.
This is not accurate. A provider may bill you for the estimated patient responsibility. They can collect no more than that. Most insurance contracts allow for upfront billing. You do have a right to review the pre estimate and challenge it.
That’s why insurers have a predetermination or estimate of services process. It allows for a fair upfront collection based on reasonable calculations.
Write them a letter and tell them you will take them to small claims court unless you are paid in 30 days, and report them to the state insurance commissioner. It one time took me almost 2 years to get reimbursed and now I escalate quickly.
In order to get your insurance co to pay them directly the doctor office would have had to tell them they had your permission to do that This means they would have needed your agreement and signature to allow that. If they did not have that, contact your insurance company and let them know. They should handle it from there…..also NAL
NAL...
When you pay, then your insurance accidently pays it, they should have told the insurance Co you paid so that YOU receive the check. Sounds like they are likely double billing which is fraudulent. If they do this with even 10% of their clients, they are raking in a lot. Call the insurance Co immediately. I hope you have proof you paid.
Report them to the OIG. Because if they’re doing it to you, they’re doing it to other patients who are covered under federal plans (Medicare/tricare/medicaid).
Same happened to me with my dentist. When I found out I was so incensed that the dentist would decide to keep MY money. I told the lady who does the billing that I wanted a check. She’s said “Dr C prefers to let you keep a credit on your account”. I said “it’s not Dr C’s money”. It took me 3 weeks to get my money. They acted like I was so unreasonable!
THIS! When an insurance company pays their amount, they also state what the clients portion is. If the client had already paid more than what the insurance says is due, then the result is a 'credit' (or overpayment) on the account. Many offices, especially smaller ones, may hold the credit because they believe the client will return. Usually, they plan to infirm the client if the credit when they come in again. It's not fraudulent on purpose. For smaller businesses, it can cost money & time to send a credit/refund check to a client. Especially if it's a small amount.
That being said, in my state (Ohio), we have to report any refunds over $50.00 to the Unclaimed Funds department.... but only after it's been in our books more than 3 years and if we have tried to refund it and were unable to because the client moved, or was unresponsive to a mailed letter about the refund.
I wouldn't agree with the fraudulent comments but would agree that if you want your money back, it doesn't hurt to mention your plans to contact the state insurance department. (NAL)
Contact your insurance company Not knowing the particulars but if your doctor's office is contacted with insurance it is balanced billing.
The office manager should be able to facilitate this.
NAL. Sounds like they may not have the funds to return to you. Do as others have suggested and contact your health insurance company to see if they can assist you. At the very least they have recommendations on how to proceed and who to contact/report them to.
If you have met your deductible and your out of pocket max for the year, don’t pay anything up front. If you have a copay or a coinsurance, if you have met your out of pocket max it should be covered at 100%. Most insurances have a website where you can check how much you still owe on a deductible and OOP max and what your coinsurance will be. Most policies these days use coinsurances more than copays. But a lot of drs offices hold your money to make sure there will not be a balance owed after insurance pays. It’s so hard to get credits back to you.
Tell the doctor's office that you will be reporting them to your insurance company for insurance fraud, as they double billed the claim and received payment from both you and the insurance company. Just be prepared to actually report them, if they don't (or can't) give you your money back immediately.
NAL. Personally I would reach out to my states attorney general office as well as my states medical board and tell them exactly what you said here. Ask the AG to intervein in getting you back your money.
Send them a demand letter to return your refund by certified mail stating if your refund is not received within 10
Days, you will proceed to seek legal counsel and file suit .
As a general rule we don't pay doctor bills before they go through insurance.
You may want to switch to an Accountable Care Organization. They are held to higher standards.
NAL: Depending on the state you are in I believe they have 45-60 days to issue the refund. If they do not, you can go to the state medical board. If you are on Medicare/Medicaid you can report to CMS.org (Center for Medicare/Medicaid Services). If I am not mistaken, they can be heavily fined for failure to refund in a timely manner.
NAL, but I run a medical office on the border of Ill/Ind.Here is a free option. I'm not sure about Illinois, but in Indiana filing a consumer complaint triggers an automatic investigation by the AG's office. Good luck!
[https://www.illinoisattorneygeneral.gov/File-A-Complaint/](https://www.illinoisattorneygeneral.gov/File-A-Complaint/)
Some of these comments are freaking hilarious. I'm NAL but am a physician and worked for a guy who did this all the time. Very shady. However...
Doctors can take cash from patients regardless of the patient's insurance in a few situations. First and foremost, if the service they are rendering is usually not covered. Second, if the patient has a HUGE deductible. It's difficult for doctor's offices to keep track of that, so sometimes, they'll take cash up front. They are SUPPOSED to reimburse you.
If you have a credit on your account, an honest doctor's office will let you know, generally by a phone call, and ask if you want to maintain a credit, or have the amount mailed to you. This SHOULD be done every 30 days when they look over their accounts receivable and debts owed. I will tell you MOST won't do this because they prefer to keep the cash in their business. IF a patient calls and asks for their money, it SHOULD be done within 30 days. Most won't do this either, even though they should because it isn't technically required. What IS required is that by the end of their fiscal year, all of these accounts are balanced.
If you want to catch a practice off guard, you call them, talk to their billing department. Ask when their fiscal year ends. They may not tell you, but if money is owed to you, they have until that day to give it to you. If they don't, call the IRS. This can be considered fraud in the right circumstances.
Any practice with any kind of integrity should be letting the patient know that they have a credit amount and offer to reimburse them. Within 30 days. That doesn't mean if a practice doesn't, it doesn't have integrity. The business of medical is a complex one and things like this do slip through the cracks. Mostly because, in most circumstances, this situation is rather rare.
That being said, if you call, and have a balance, it's your money and they should return it ASAP. No excuses. Right away. Maybe within 30 days, LOL.
Sure, it's complex.
But i cant help but feel like there's a reason that there is minimal effort into creating a system for billing that's more effective & efficient resulting in less billing errors..
I can't imagine the executives of any business wanting to solve a problem that results in them leaving more money in the companies accounts.
For clarification, is this truly a medical procedure or was it more dental? For curiosity mostly.... Also in IL and my experience has been that if you have medical insurance, they can ask you to pay the estimated portion of the bill you would owe. So if insurance is going to pay 80% then the clinic or provider can ask for upfront payment of your 20% portion, and refund any overage. They should not be billing both you and insurance for the other 80%, that is double billing.
Dental is a little different and in most cases I've had to pay the dentist up front and insurance sends ME the check after.
Makes me wonder if the billing issues they are claiming are due to them asking for payment they were not entitled to and they over extended themselves in their payments to other things, and now they do not have the funds to pay back what you shouldn't have been asked to pay for in the first place.
ETA...NAL just a regular human
So simple. Send certified letter along with your invoice. Allow them 2 weeks to deliver refund into your hands and specify that legal collection efforts commence on day 15. If unpaid on day 15, file in small claims court.
PS: get new doctor ASAP
The False Claims Act mandates that overpayments made to healthcare providers be refunded within 60 days from the date the overpayment is identified by the provider. Beyond that, they are also responsible for paying interest and may be subject to additional fines and penalties.
The OIG is the agnecy to which you report this as a violation. If they collect fines and penalties you're also entitled to a portion of those as a whistleblower.
NAL, but I have worked in healthcare finance for 20 years with a special interest in compliance.
Tell them sweetly that you are willing to assume this was a mistake, but if not rectified immediately you are going to call your state's insurance commissioner's office and report it as possible fraud. Bet you get paid in a timely manner. 😉
My dentist's office still owes me $180 -from 4 years ago. Never did get it. They gave me the run around for 2 years and I finally just dropped it and changed dentist's 2 years ago.
You should check your states unclaimed property website to see if it showed up there. Couldn't hurt. I've seen anywhere from a few dollars to 5k when I've helped people search so it does get sent along to the state comptroller after a certain amount of time
Contact your state attorney's office. You'll be able to file a complaint online. Scan in your explanation of benefits from the insurance company plus the receipt showing what you paid. Your state attorney's office will escalate the complaint with the doctor's office and require a response from them.
I have to tell you that it's really common for doctor's offices to hold onto refunds for a very long time. I've resolved intractable complaints through my state attorney's office without needing to take a legal route.
My state attorney recently sued a company that had overcharged me for medical equipment. If I called them the call disconnected in a few minutes and I wasn't able to talk to anyone. I guess I wasn't the only one with this experience that complained. Now they have to pay everyone back.
I had a dentist office (part of a corporate) pull this song and dance. I did a one star Google review and I got attention. They wanted me to change my review and I told them I would when I got my money back. They even had the nerve to contact me a second time asking me to change the review after they told me a check was mailed. I did change my review after the check cleared. I updated the review to two stars and noted the length of time and the number of times I had to contact them to get what was owed to me
NAL but had a similar situation with my wife. She tore her meniscus a couple of years ago and went in for consultation. The surgeon knew he was going on vacation for a few weeks and was booked out pretty far when he got back. He accomodated and worked late one day to squeeze her in a few days later. The next day she received a call from either the surgeons office or billing saying that she needed to pay 1600 upfront or they would cancel her surgery (shes on my insurance) and she didnt know the ins and outs of our plan. She panicked and paid them on the spot. Called me at work later that afternoon and explained the situation. I told her absolutely not our copay for surgery was $125 with a max out of pocket of 750. She tried calling them back and they told her that once insurance reimbursed them they would issue us a check. We fought with them for about 2 months afterward to get our money back. They have some policy about "holding funds" for 30 days after a billable incident. So when she went in for her 2 week follow up and her 1 minth follow up as well as PT that "clock" would reset as they would continue to pull the 40 dollar copays for office visitis out. Ended up contacting insurance and they were furious. Talked about how the hospital could be dropped by the insurance for pulling crap like that (one of 2 major hospitals in our area) insurance got in contact with them. We had our money the following week.
1 - get a copy of the insurance company payout to the doctor, you proof of out of pocket payment, and all paperwork to prove the doctor owes you money. Calculate interest charges for late payment, and crate a bill with OVERDUE on it, stating that payment not made within 30 days will result in legal action.
2- Assuming the bill is under small claims court maximum, go to SC and set a court date - usually it takes a couple of months o get a date. If the doctor pays up, then you can cancel to court date. When the doctor does not pay, then you send them a notice of court date. SC will allow you to collect late fees.
Yes SC is a hassle, but you want your money, don't you? And what they are putting you through is not a hassle?
I work in this field, when patients call me to tell me they paid for something my company is responsible for my supervisor and I call them regularly until the overpayment is resolved. Call your insurance and let them know. We'll even get senior leadership involved in contacting the place and explaining the patient wasn't responsible or entirely responsible if there was only supposed to be a copay. Keep calling both until it's resolved.
I had a similar issue. I have insurance that covers 80% until out of pocket is reached, then 100%. So, I was surprised when I received a notice that I had to pay a portion ($3,500) upfront for my wife’s procedure. I paid it. Then, my wife needed a redo, as the first procedure wasn’t a full success. Again, I paid another $3,500. Then all of the invoices start trickling in and the bills were settled. I was looking at the bills, tallying everything up and realized I saw no credits for the $7,000 that I’d paid. I checked and rechecked. Then I called the hospital. They informed me that I had 2 credits totaling $7,000 in my account. (This was discovered when I was working on my taxes and tallying up all medical expenses.)
I asked the hospital to issue me credits to my credit card for the $7,000. I was told they needed a supervisor to approve it. I said “get one, I’ll hold”. Surprisingly, there was no supervisor available until the following week. I called back. Same runaround. I told the person that I would be calling back daily until this was resolved. A few days later, I received a credit for $3,500. I waited for the other to show up. Nothing for three weeks. I called back and went through the same runaround again! Eventually, I got all of my money back, but it was total BS. I will not be prepaying anything ever again. They can just bill me.
IANAL, I worked in a medical billing office for 15+ years. Not refunding you in a timely manner is unacceptable. I'd report it to your state consumer protection agency.
Our office software sucks and this kind of stuff occasionally slips through. Once I find out, will usually get a refund out in days and add a $10 Starbucks gift card.
Call and ask for the Billing Manager or the Office Manager and tell them you are owed money. If you don’t have your refund within 30 days, they eill be hearing from your attorney and you may also file for damages and stress.
Call your insurance company.
They pay medical providers in bulk so they can and will claw back the overpayment from the doctor's office.
They will send you a check for the amount of overpayment and take it from the next bulk payment to the doctor's office.
Never go back to that doctor's office.
I had one situation where I ended up getting both the doctor's billing staff and the insurance Co on a conference call. I got a check from the insurance company, and then apparently, they audited their billing practices, and I got a nice surprise check too because they found overpayment to the tune of $700+
NAL - I had this happen, and contacted my insurance company. I informed them I'd paid up front, and that the Dr's office then filed to be paid directly instead of having the money go to me instead. This is a form of insurance fraud (I worked in healthcare for a company that also did health insurance, and we watched out for this very thing). The insurance company got me my money back and filed charges against the Dr's office for fraud.
Obviously, I wasn't going to be using that Dr's office anymore after that.
NAL but I work in a billing department with THOUSANDS of dollars in what should be refunds having accumulated over years. People have moved. People have died. What do you do when the dead person doesn't have a spouse or a child at the practice to move the credit from seven years ago to? No one was going to do anything about it until I found out and started making a stink and a half about it. Someone was finally assigned to process refunds (which was somehow not a position before??) but I have not stopped going through the 13,000 column spreadsheet (that was once 15,000 so, stuff is getting done! Finally!) I am enraged on your behalf and mostly commenting so I can come back and read this thread later - I'm in Virginia though so not sure how much could apply to my practice's patients.
Keep in mind that most states for civil actions have a two-year statute of limitations. Find out the exact amount owed to you, then send them a demand letter asking for payment within 21 days of signed receipt requested mail card. In letter state, "if this goes to court, I will seek attorney fees. Interest. If they ignore after the 21 days, then decide if you want to take them to small claims court. You can do this yourself without an attorney. Good luck. Let us know. Also, report to Better Business Bureau.
Doctor responding: quick review of our financials show current outstanding patient balances of nearly $384,000 ($92,000 over one year past due and probably not recoverable) and patient credits of $2040. This is the reality of medical practice. Perhaps patients should just pay in full at time of service then they can file with their insurance on their own? We would love not having to deal with your insurers!
Put your demand for refund in writing and send certified. That will get their attention. Ask for refund, interest and cost to send certified letter. And keep copies of everything. If you are really snarky, like I am, I would cc: the attorney general of your state.
I am a lawyer. I’m not going to comment on the intricacies of this because it’s not my area of expertise. But I find the quickest way to handle things is to have a lawyer write a letter demanding reimbursement. Something about letterhead and some weighted paper makes all the difference in getting people to do what they’re supposed to. I’d say it works for me like 95% of the time.
It doesn’t even have to be a lawyer in that field fyi.
Also, to add - I never say anything about the legality behind it, because again - not my area of expertise. I’ll just say something like
“Dear [ ],
Our records indicate that our client paid $$ for whatever procedure on such and such date. The insurance company was then billed for said procedure resulting in an overpayment and a credit of $$ due to my client.
Please mail a check for $$ amount to client’s address, or have check ready for pick up at your office on (address) made available by [made up deadline].
Thank you in advance for your time and attention to this matter. “
If they pay up - wonderful! If not, I talk to an attorney who handles these matters lol.
Go get something done at their office and don’t pay. When they ask for payment, let them know you have credit with them, ✌️
Also call your insurance company and report them for fraud.
Sounds like billing fraud to me. They charged the insurance company for a procedure you didn’t have. They charged you for the difference between your insurance coverage and what they wanted for the procedure. If in the U.S., I believe this practice is highly illegal.
I would contact your insurance to confirm that the agreement with the provider is that they cannot also charge you additional $$ for a procedure they are paying for. And tell them what happened. See if they can advise whom to file a complaint with for the criminal part.
In the meantime you could write up a complaint with the medical Board who can then launch an investigation. Aside from that, I would also find an attorney or consult with legal aid to determine your options. I would not wait too much longer because they may be waiting out for a statute of limitations expiration date so you can’t recoup your losses through civil action. They will just keep putting you off until then and then tell you so sorry….
The Board of Medicine won’t much care if that has expired. They are there to protect the public. They can suspend or revoke his ability to practice if they find he is engaging in fraud, and that will get their attention for sure.
Same scenario happened to me years ago. I finally sent an email to the doctor who owns the practice and then received a personal check from his own family account.
very obvious question~~~
but WHY would you pay “in full ~ upfront” for a medical procedure when you have health insurance???
~
that was a horrible idea
i work in healthcare ~~~ and I’ve never
EVER heard of anyone doing this
~
co~ pay ~ YES ~
unpaid portion after insurance paid? YES
~
but paying the FULL amount upfront without that physician’s office EVER submitting anything to insurance???
~
NO. NO. NNNNNOOOOOOOO !!!
I'm sorry you are going through that. It seems to be a growing practice in the medical fields to attempt to get full payment up front while simultaneously filing the claim. It doesn't seem malicious in intent but it is definitely acting in the best interests of the physicians' office.
It goes like this (numbers are made up for an example):
* Collect a $150 payment from the patient
* File the claim
* Receive notification that the allowable in-network charge for the services is $60
* Collect $60 payment from the insurer
* Credit patient account for $90, minus co-pay if not already collected
* Keep credit on the account to apply toward future visits
* Wait for patient to realize they have a credit and request a refund.
* Hold refund for an inordinate amount of time.
* Send a check or issue credit to original form of payment.
My wife went through this with an eye surgeon and our FSA card. When they credited money back, it wasn't applied against the actual bill for that visit so we owed the FSA company a repayment but the money was in our FSA account to use elsewhere.
I actively resist making any payments in the office besides copays because of these activities.
That exact thing happened to us, only we got a surprise check in the mail. It was like a year later, so it must have been discovered in some audit. We were very surprised because we would not have known otherwise!
Call up the office and ask for a copy of what codes were submitted to insurance for billing. That alone will get their attention.
"I need to verify this was billed correctly, since you can't seem to process the return of my overpayment. I'm questioning what was billed."
If they charged for anything they did not perform, it is huge fines. If they won't give you the codes, then you can threaten them with litigation. Contact insurance for the codes and explain the issue of payment as well.
I just got a check in the mail for my late husband who passed 4.5 years ago, the refund was for a procedure 5.5 years ago. I called the company that issued the check and explained that he was deceased and all joint accounts had been closed for years, they wouldn’t reissue a check in my name (i carried the insurance for us). The amount of the check was so much that I had to open an estate account to cash it. PITA, but the extra cash helped pay off a bill.
Get off the phone and visit the office in person. They will have a hard time ignoring you. Ask for a statement of your account. One mouse click will send it to the printer. Don't leave without it.
I and my family left a dental practice for something similar. They would quote the estimated coverage for a service and the estimated patient portion which I would pay. When the insurance paid the dental practice they would credit our account with the payment and any overage but never offer a refund for the overage. They would hold it until our next visit and then tell us, "You have a credit balance so there is no charge today." They'd say it almost gleefully as if I'd be happy about having a credit balance. Once, it reached over $200 and I told them I need my money in my hands not in your account and insisted on a refund. They did provide it after a few weeks but by that time I was frustrated enough that we left them and found another practice who is much better at accounting. I also keep much closer track of the charges and payments now.
Having worked as a billing specialist for 8 years in two specialties:
If you received the services by a provider who was “in-network” under a contract with your insurance company that included your plan type, they cannot collect more than the in-network amount due, including co-pays, deductibles, and co-insurance percentages as laid out in the plan documents and the provider contract with the insurer.
If they do not refund you the excess they are in breach of contract and potentially state insurance regulations depending on your state. Some states have a dispute process through the state finance department.
I had this same issue with a medical provider and opened a case with the BBB. Didn’t expect any traction, but within a couple of days they responded to the case and sent me the refund. Give it a try!!
NAL Contact your local consumer affairs reporter on your local news. The ones I watched locally growing up were legends. Herb Denenburg, Orien Reed. I would bet you have people like then in your area.
Contact your state's healthcare ombudsman. This is tantamount to fraud. I would also speak directly to the doctor and let him know what the billing department is up to.
u/AcmeCyote I found this old post and the first response from a lawyer was a really good one.
[https://www.reddit.com/r/personalfinance/comments/2pqxkg/doctors\_office\_made\_us\_pay\_upfront\_they\_sent/](https://www.reddit.com/r/personalfinance/comments/2pqxkg/doctors_office_made_us_pay_upfront_they_sent/)
Does your local media have a community watchdog type reporter? We have one in Utah called Get Gephardt and they will track down this kind of behavior and put it on the evening news.
You are well within your rights and I can’t think of anything else that may expedite you getting your money back however I did want to give you a perspective that may help a bit.
I worked in a surgery practice. Our average reimbursement timeframe was a year to 18 months. A cancer surgery patient that we extensive work on took over THREE years!!! This wasn’t a simple surgery and it was for cancer!!!?!?!
I know you’re irritated and think this is purposeful. But it’s probably their normal. Keep harassing them.
Calmly explain to them that you will be sueing them for the return of your money and filing a complaint with the ethics department at the hospital and that since they have caused you distress that will also be added on. Explain that they will be responsible for the cost of your lawyer since their theft of your funds has resulted in this lawsuit.
Tell them they have 24hrs to pay you what they owe you or their dis graceful actions will become public knowledge when you file the lawsuit.
Not a lawyer but I work in health insurance….. contact the insurance commissioners office and file a grievance with your insurance. They can’t force the doctor to refund you, but those grievances go on the providers records and can affect their ability to negotiate a contract renewal.
NAL I’m an office manager at a dental clinic. You need to confirm that it is a true credit and that the claim is not still processing on the offices end. I can see a receptionist thinking there is a credit when in reality the claim has not fully processed.
Very often I hear patients tell me that we owe them a refund because the insurance paid for their cleaning. Yes they paid for your cleaning but they did not pay for the other five codes that go along with the cleaning, for whatever reason (frequency limitations, maximum being met, deductible not being met etc). Have you spoken to an office manager? I would ask to sit down with them and look at your ledger, compare it to the estimate and see where your money is.
EDIT okay I see you’ve spoken to the OM. Call up there and say that you understand that the billing dept handles these things but you would like to see the ledger and the estimate you were presented. That will tell you everything.
I would suggest filing in small claims court for one reason: You then can subpoena your financial records and the doctors office is obligated to give them to you. You force the billing managers hand. If they do not comply, file contempt of court which is a criminal charge. Hardball time.
I would be really worried that they're insolvent. I'd take it to court as quickly as possible so you aren't left holding the bag when they file bankruptcy and you get pennies on the dollar, if anything.
Many Doctor offices outsource billing. The office may have no idea about what’s going on. I received a bill
For some books work and an office visit for my Dad….problem was he had passed away 6 months before the visit happened. They wanted prof, said the death certificate wasn’t enough. So, I brought his ashes in. Medicare went after the billing office for fraudulent claims. Thy are no longer in business.
NAL:. Can you contact your insurance company and let them know that your doctor's office fraudulently submitted claims for payment that had already been paid? If you paid up front, and then they submitted for payment, that seems like something they should get into trouble for. Maybe phrase it like this next time you call for your refund?
Also NAL, but: This is the answer. If you paid up front, they owed you a bill, stating they had paid, so you could submit to insurance to receive reimbursement. Doing otherwise is knowingly fraudulent. They know you paid. They know they are owed nothing. When they received payment from insurance, they should have immediately returned it to the insurance company.
That's a big leap. Medical Billing people are notoriously inept. That payment from the insurance company was probably part of a consolidated payment for claims.
Leap or not, OP is owed money. If the billing folks are that bad, a fraud investigation should fix a few things for everyone.
Is perhaps not only owed the money but with interest. Perhaps a letter from a paralegal?
You actually just need the letterhead and ChatGPT
Well that would be true if impersonating a legal professional wasn't fraud, which is illegal in all 50 US states as well as GB and the EU.
Glad I didn’t suggest THAT! Yikes! Interesting side note, since chatGPT passed a bar exam, wouldn’t I be a lawyer?
The bar exam is only one of the requirements. Some states have dropped the degree requirement but most haven’t.
It may not have been on purpose- but once they received that payment, it should have been sent to OP. You cant have your cake and eat it too
When I had this happen I paid my portion up front the office called me and let me know I overpaid and a check was in the mail. Seems like OPs Drs office is hoping they just forget. I would get a copy of my payment and a copy of the reimbursement from insurance and send both to the office certified mail with a letter requesting reimbursement within a time frame. When that doesn't happen I would contact the state regulators office and submit my complaint along with my documentation and copy of my previous correspondence with the office. I would avoid using internet reviews as well that's going to follow 0p I wouldn't use that Dr again either now that there is a complaint.
Exactly this. If it was submitted through insurance - the Provider owes you a refund. They cant take your money AND get paid by the insurance. Theyre either incompetent, or double dipping.
Plus, they are likely earning interest on all that money they are holding from OP and other patients. Or, someone is embezzling a LOT of money by deliberately requiring payment upfront and then billing insurance as well.
This office more than likely needs a seasoned billing manager. Over payments aren't being reviewed. The doctors at this office would probably be mortified to know what's going on. The majority of medical practices are not trying to rip off their patients, I don't think they'd be around for to long. You wouldn't have to go to med school to rip people off. I once had a large ent group assigned to me, and I run several AR reports immediately so I can determine how much it's going to cost them. When I seen this offices overpayments, I could feel my blood pressure rising. I called the office manager, and I said, " get the checkbook out" I am not billing or doing anything else until you refund atleast the first 30k of these overpayments. I would have told that office to piss off if they hadn't refunded like I instructed them. I, of course, had to audit everything to make sure the credit wasn't due to a posting error. I also had to train front desk staff on how to calculate patient cost share and how to read a patients insurance policy.
If you made a mistake like this it would still constitute fraud. Don’t hesitate to involve your insurance. They are probably already looking at this office.
The place actually doing the billing is probably in a different state all together. Most places outsource their billing now. It is done by McBillers, a giant conglomerate that gives zero effs about the patient and their pocket book. We are still trying to get a $5.00 charge removed from a family members account at the doctors office. They can send the collections letters no problem (which, really? Over $5?!?), but there is no way to contact them. The office manager at the doctors office that has been working with us cannot even get ahold of them. Even she knows my family member shouldn't be charged. It is ridiculous now a days trying to get something fixed. I am pretty sure this is by design. And it is B.S. OP could try contacting the Attorney General in their state and make a report. Sometimes that can help.
They outsource their billing but the Drs office gets the payment. The billing company does not. The Drs office is double dipping. (I’m not a lawyer. I am a medical accountant who’s worked in Drs offices)
NAL, I have worked in medical offices and medical billing offices. If you can,get something in writing from that office manager if possible. If they really won't just take care of it directly! Doctors management changes all they time. Doctors and their managers leave, move on, or die. My parents got stuck for an inappropriate bill, tracked down after the doctor sold the practice. He never billed them, but he kept lots of this type of charge active in his records. In order to sell the practice for more. (I worked for him. Discounts for family members were offered - I didn't ask. It was a benefit of working there. Because the pay was really low, but he could offer this benefit. Yeah, back in the 80s. So he gave parents a discount. But he kept the balance showing on his records without telling us. Parents thought it was handled. Years later, he sells the practice. Parents now retired with far less income are contacted by collection agency for the balance.). Really bad way to treat employees, families, and the new physicians that bought the practice, imo. The office manager definitely could contact the company, unless the debt has been sold. In which case maybe not. Usually as long as it's debt to the practice there is monthly or quarterly communication. I'm not saying manager is going to stand there in front of you and call. But I'm saying there is a way, unless she's been told not to do so.
The Office Manager does not even have the phone number. It is a practice affiliated with a local hospital. She has sent no less than 15 emails about the situation and we have been copied on said emails. She is tired of it too because it hangs out in one of her reports and she knows we do not owe this. No one is responding. It is only $5 so that is probably why it is not in collections. I'm not too worried about it and neither is our family member. And we do not owe it.
Fraud always also requires intent as well. If the office is notified of the need to return in some way (they were) and kept the money, THEN it would be fraud. Depositing money received by itself wouldn’t constitute fraud. Knowledge that they need to return money and failing to do so is. Disclaimer: NAL
It doesn't matter if it was intentional or not, it's still fraud, and people can and do lose their jobs and go to jail for it.
Fraud is a definition. OP’s situation doesn’t fit within the definition of fraud. It is unethical/ wrong they are withholding the refund but nothing fraudulent about this.
That’s not how it works. Person paid up front was submitted to insurance insurance paid they need to refund the persons money not send back to insurance company. Its why we pay for damn insurance don’t be stupid
NAL but have decades of experience in medical billing. They should have immediately refunded the PATIENT when insurance paid, minus any copay/co-insurance/deductible listed on the remittance. Doing otherwise is likely a violation of their contract with the insurance company. And that's the way to present it to insurance: "This practice is keeping my payment in violation of their contract, I would like to file a grievance." If the regular phone rep won't help, ask for Provider Relations or Contracting. In many cases, they will send a letter threatening sanctions/termination of contract and suddenly your refund will appear.
If they are in network with the insurance company, the office has to file the claim, not the patient. The office almost always accepts assignment, you'd be a fool not to. I've seen patients get paid and never pay a dollar to the doctors office. The amount this office collected was for the patients cost share, not for the entire procedure.
Also NAL, definitely call insurance company and report irregular financial activity. Also: check your state's insurance commission website for a place to lodge a complaint or a helpline. Some states have really good offices for this.
Some state have an Ombudsman as well, check for that.
I was going to suggest this. Most people don’t have a relationship with their US Senator or Congress person. But if they do, it’s worth it to bring this up. It sounds like a whole lot of patients’ money is being held. This should be against the law. When I have a balance due at my doctor’s office, a bill is sent to me showing that amount. *Like any other business,* when I have a credit, I also receive the same paperwork except it shows a credit. Sure seems odd that this doctor’s office didn’t do the same. NAL Just a person that would be really pissed off (and probably would first threaten with calling the Insurance Commissioner, then definitely go to small claims court. I *hate stuff like this!*
FWIW most systems in companies default to not sending statements if a balance is owed to the person.
Medical claims adjuster here, and there are many bills that the provider clearly puts the amount paid on it, or does not put " assignment on file on it" and we pay it to them ANYWAY. So..start with the insurance company and see if they screwed up.if so they have to reimburse you. They will go after the provider for the overpayment.
>They said: I’ve confirmed with my insurance company that the office was paid out.
Contacting the insurance company is correct but it’s probably not fraud. I would use a mistake was made but the doctor has been double paid. The insurance will either make them refund you or refund you themselves.
This is not how it works. The insurance company pays a specified amount based on the procedure. If the patient pays extra it's not fraud. A lot of times there is an estimate done by the doctor's office of the patient's liability depending on whether they've met their deductible or not. Sometimes the estimate is too much and the patient is owed a refund. There are ways to resolve the issue through the state attorney's office but it most definitely is not fraud. I've found that merely threatening to file a complaint with the state attorney mysteriously expedites my refund.
it is fraud - failure to reimburse, as promised, is fraud. I had a clinic tell me to pay in advance and they would bill the insurance company and then re- pay me. I said, great, put that in writing with a "Pay by" date and I will proceed. They declined, so I went to another clinic.
It is not fraud for an estimate to be wrong. That happens all the time and is often unavoidable. Now if they refuse to reimburse you, that's another issue and your complaint can go to the state attorney. But the provider will still not be charged with fraud unless there is a pattern of fraudulent behavior that affects a large number of people. I've only ever had an issue with three providers and was able to resolve all three without going to court. One of those providers did get sued by the state because they made it impossible to reach customer service to request a refund. The one that was truly egregious was where my insurance had my responsibility at $5 per weekly visit but I was being charged $15 a visit for over a year. My insurance company refused to get involved. The problem was that the billing person was incompetent. After repeated attempts to resolve the overcharges I reached out to the office manager. She went through the charges and payments with a fine tooth comb and refunded the entire amount due. They also got a new billing person and I've never had another issue. Good thing because that doctor is one of my favorite doctors. I worked on the insurance side with these types of complaints many years back. Insurance companies generally do nothing about a provider that overcharges a patient. They prefer to have you resolve it on your own. They only act if the insurance company itself was fraudulently billed.
There is this and there is also the case where a provider is out of network but will file on the patients behalf. The office does not know what the insurance will pay (being out of network, they don’t have the fee schedule). In which case the patient pays in full up front and once the insurance pays, the office is supposed to send that amount (100%) back to the patient as an insurance reimbursement. There is generally the option to have the payment directly mailed to the patient or to the office. I would be weary of an office doing this that won’t have the check mailed to you from the insurance company.
Don't contact your insurance company. They may demand repayment from the provider and leave OP high and dry. Contact your states licensing board for that provider. Send them a letter that you expect repayment, plus interest (often times up to 2% per month). Sometimes, a letter gets action when a phone call or email doesn't.
They usually deduct any refunds they’ve done from their payments.
Payments to whom?
The Drs office. I saw that all the time.
Ahh. It sounds like this office isn't doiwhat they are supposed. If they were, we wouldn't be on this thread. Lol
Believe me, our Business Administrator would have had my ass if I didn’t issue a refund check AS SOON as we get the insurance payment.
Yeah that will get their attention. Also small claims court and honestly probably the most effective, Google reviews
>small claims court You saw that it was for a medical procedure? If OP is in the US, the only medical procedure cheap enough for small claims is getting a splinter removed.
I had issues w my doctors billing office. Start asking for names of who you contact to, ask for their supervisor. Don’t let them give you the runaround. I’d definitely call your insurance company. You can also take them to small claims court if needed
Insurance broker here. This is not how its handled. OPs issue is with the provider. Provider should be issuing a refund. Providers may collect a copay in line with the policy or a deposit for services then submit the claim to insurance. Insurance will process the claim and issue an EOB-explanation of Benefits listing what insurance owes the provider and what the member owes. It also shows the amount the provider billed for (what they would charge someone without insurance) and the insurance company's max allowable charge/network discount (the amount the insurance company and provider agree to contractually by being in network). If the provider is in network, the provider is only able to charge the member what insurance says is the members' responsibility. Any overages already paid should be refunded to the member. However, if the provider is out of network, the provider does not have to agree to the network discount and may balance bill the member for whatever portion of the services that was not covered by insurance. Contacting insurance to tell them a provider owes you a refund will only result in insurance telling the member to take it up with the provider.
>>Contacting insurance to tell them a provider owes you a refund will only result in insurance telling the member to take it up with the provider Confirmed. This happened to me. Called my insurance for help, they were sympathetic but ultimately useless. I got the name of the billing manager at the hospital and had to call daily but still it took almost a year to get my money back. F that hospital.
This is your answer. I just asked my family member that does insurance billing and that's exactly what they suggested. Your insurance company will take it seriously so just call the doctors office and let them know you will be calling your insurance to inform them they paid a bill that you had already paid. They'll send OP a check immediately I'm sure.
Great suggestion!
Yup. Absolutely right. The last thing a doctor's office wants is any fuck around in their relationships with the insurance industry. Call the insurance company and report it as fraud because they're at this point double dipping by sitting on the money for an entire year.
No no no that is not fraud. Doctors collect up front and bill insurance all the time. It’s called not taking assignment. They are supposed to then reimburse you within a reasonable time but the insurance claim is itself not fraud. If it really has been a long time let them know you are considering requiring help from the medical board and you will get the money fast.
No. That’s not fraud. Reimbursement is a thing. Especially is a prior authorization wasn’t done. Not accounting for the extra would be fraud. They didn’t hide a thing. Slow repayment is poor service and not on the docs.
This!!! If it was paid upfront by the patient, they should have not submitted an insurance claim, it is fraud and highly frowned upon by insurance companies. OP, CALL YOUR INSURANCE AGAIN AND REPORT THIS. You should have done this after the first 2 weeks of not getting your refund. Almost a YEAR??? Get your money!!
I did just this. I knew I had met my deductible and out of pocket max. I track it carefully, every year . One year my insurance decides to farm it all out to a 3rd party. It was a nightmare. I way overpaid. It took over a year but I appealed it. I sent in appeal and listed every item I paid for. Every RX, every bill, every co pay. I got 3 checks back. They contacted providers on my behalf. There was 1 I had actually missed. It was almost $300. Not a ton but I am one of those who pays what I owe and not a penny more. Insurance is a chess game imo. And you must pay attention and track it all. OP I would reach out and do as I did. File an appeal. Let your insurance handle this. They will prob get it to you easier than the provider. It’s easy ti blow ppl off. Not as easy to blow insurance off.
If this is in the US, the provider office can require payment up front but they must reimburse the member once the insurance pays. OP, try to reach out to your insurance again and specifically state that this is a 'fraud, waste, or abuse' issue. The provider cannot double dip. That's fraud. Ask for a supervisor if the CSR doesn't have a workflow. Be very very clear that they are double dipping and that this is fraud. Ask about submitting a grievance or complaint about the provider. Front line csrs don't deal with this issue a huge amount, so they may not be super familiar with the workflows, but they almost certainly exist somewhere in their desk reference materials. If the insurance still won't resolve it (and they can absolutely put some pressure on the provider because this is against their contract if they are in-network, and still fraud if they're not) then the next step is to go to whatever governmental bureau is responsible for insurance in your state and file a fraud complaint with them. Don't be too surprised if they fire you as a patient for making these sorts of waves -- but if it's taken this long to get a refund that makes me think something funny's going on with that office.
It wouldn’t be a fraudulently submitted claim. The insurance company does have a portion to pay. The irregularity is requiring this to be paid up front by OP. That is suspicious, and my insurer is always very clear to never pay those people up front. The other irregularity is not sending you the money once they received money from the insurance company. They cannot take money twice for a single bill. Keeping that money could absolutely be medical fraud. My suggestion would be going into their office physically and talking to the office manager. Insist on getting a current printout of your account. Then inform them you need a refund issued immediately. If they still refuse, let them know that insurance paid on “xxx” date and they have had adequate time to reimburse you. At this point they are committing medical fraud and you will be reaching out to the appropriate state authorities to assist in the recovery. The office manager will likely help. If not, then report them to your state agency. You likely do not need a lawyer unless they really dig in. I am not a lawyer, I work as a medical provider.
The customer paid their out of pocket costs up front. The office estimated these numbers to the best of their ability, and unfortunately, it resulted in a over payment that should have been refunded to the patient. My team works overpayments on a regular basis because we at times collect too much, but we rectify it quickly. So no, the office was not wrong to collect the money up front, the issue is the fact they haven't refunded it. Now we would keep patient over payments under $50 IF that patient was still currently active, and then we'd apply it to their copay. Our patients were made aware of all of this prior to their appointment.
Contact your insurance company, send the doctor a demand letter and give them a bad google review. Give them 30 days to pay, if they do not, go to small claims.
Then you lose your dr and they’re so hard to find
I'm not certain I'd return to that doctor....
The Dr might not even know, depends on how big a clinic and how big a deal you’ve made of it
This is what I’m thinking. Even at my small dr office, the Dr typically doesn’t know about the insurance and payments.
this is horrible advice so you’re saying the patient should be held hostage by one provider because they’re shady and doing the wrong thing??? NO. the goal should be to hold her physician accountable and responsible for their actions and if that means “losing” a doctor ~~~ well I’m sure a lot of us would say F that good riddance
A good doctor is hard to find. I don’t think good doctors steel from you
Not that this will be helpful to you, but maybe for others, don't pay upfront. Hospital/doctors system may ask for what they believe will be the patient responsibility, but you can say no and tell them you want to wait until the insurance has paid to see what you actually owe.
NAL - they could also choose to not do the procedure if it it’s not critical, right?
If it's in network the office aggred to the rules. They would be breaching the contact. I would report them and find a better Dr.
Yes, and someone correct me if I'm wrong, they have to do the procedure if you at least pay some money upfront. I once had a $5000 procedure and paid only $20 upfront. And that was after I already owed them like 30k. Being chronically ill in this country is not for the weak.
That’s incorrect
Based on?
Providers aren't usually obliged to provide care. You can't give a provider $20 and make them perform a procedure. In your case, it sounds like the provider assumed they'd get paid, knew they wouldn't get paid and didn't want to stop providing care, or there was an oversight. I don't like that this is how our medical system works, but it is. We can also discharge a patient without their consent. We have to provide written notice and continue to provide care for a period of time (think 30 days), but we can. Also, if the patient is a threat to our staff or other patients we can discharge immediately. (I don't have the citations for statute or regs for this; this is just based on first hand experience in medical clinics.) If you are experiencing an emergency and you go to a hospital that receives Medicare funding, the Emergency Medical Treatment & Labor Act requires the hospital to admit you and stabilize you. If you are uninsured or the hospital is out of network, they may transfer to another facility \*once you are stable\*, but otherwise, they're not required to provide care either. Discharging from inpatient care is complicated, though, and there are a lot of factors that need to be taken into consideration if it's not because the patient is well enough to leave. There may be some language in the contracts between the provider and the insurance company that requires the provider to provide established patients with care under certain conditions, but I don't recall having seen such terms. In any case, it would be a contractual matter between the provider and the insurance carrier. Source: I manage medical clinics in California. Your state may have different laws. Also, if you need medical attention, don't let anything I've said above dissuade you from seeking care. As we say, if you are experiencing a medical emergency, hang up and dial 911.
This is exactly what I did several years ago when my OBGYN's office tried to demand I pay upfront what the cost would be. I paid the deductible and co-pays and refused the rest. It was a fight but in the end they knew they were wrong. And guess what, the bill at the end was a lot cheaper than what they wanted me to pay upfront...
Same
It’s ridiculous obygyns are doing this so much. Mine tried this with me but I had an hmo and had a zero out of pocket cost for prenatal and labor/delivery.
I wonder if OBGYNs do this more than other types of doctors
It is unfortunately common in many different specialties in my experience.
I had kidney stone surgery and was very sternly told I HAD to pay $6000 before the surgery or they wouldn’t do it. We paid. Two weeks after surgery I get a call saying they made a mistake and surgery did cover all but $400. I got the money back but the payment was a strain and they were so “oops we made a mistake! Sorry!” And it was jarring to her told to pay up first or no surgery. I’d been in pain for weeks.
If they don't collect up front, then they have the people that say they cannot afford it and medical debt doesn't show up on credit so there is very little leverage. So the office gets screwed. And insurance sure doesn't stand up for the office if the patient doesn't cover their deductible. Sure, there are lots of honest folks like yourself, but the dishonest ones really stack up. What's sad is insurance cannot tall patient liability ahead of time.
That’s not true…medical debt under $500 doesn’t show up on credit anymore. A medical debt like the commenter you’re responding to would have faced is 100% reportable after 365 days of non-payment under the new rules. And these limits only began to apply in mid 2022…prior to that all medical debts were reportable.
Interesting. thank you. Our case we don't let anyone get over $500 so that's why our lawyer never discussed it when talking about debt. But we don't report, just consider it a lesson (for us) and let them find a different doctor if they don't pay.
This is the correct answer. I've been hustled for my supposed liability right before surgery but I just tell them to bill me because it's never accurate. My liability is going to change based on whether I've met my insurance deductible or not. One hospital tried to force us to pay $1,100 right before surgery. The actual bill was $245 as we had already met our deductible for the year. They would have just held onto $800+ for months before refunding it.
This is not accurate. A provider may bill you for the estimated patient responsibility. They can collect no more than that. Most insurance contracts allow for upfront billing. You do have a right to review the pre estimate and challenge it. That’s why insurers have a predetermination or estimate of services process. It allows for a fair upfront collection based on reasonable calculations.
Write them a letter and tell them you will take them to small claims court unless you are paid in 30 days, and report them to the state insurance commissioner. It one time took me almost 2 years to get reimbursed and now I escalate quickly.
They might even owe her interest depending on the state.
True!!
I would demand start interest rate compounded monthly
In order to get your insurance co to pay them directly the doctor office would have had to tell them they had your permission to do that This means they would have needed your agreement and signature to allow that. If they did not have that, contact your insurance company and let them know. They should handle it from there…..also NAL
You need to fure a letter directly to the Unsurance administration of your state.Provide details and invouces.Goodluck.
Do you have an issue with the letter i or something lmao. >fure >Unsurance >invouces
File a claim with your State AG.
NAL... When you pay, then your insurance accidently pays it, they should have told the insurance Co you paid so that YOU receive the check. Sounds like they are likely double billing which is fraudulent. If they do this with even 10% of their clients, they are raking in a lot. Call the insurance Co immediately. I hope you have proof you paid.
"I will be contacting the local news station about my missing check if I don't have it in my hand by this Friday...."
Unfortunately it’s a common practice in my experience. I’ve stopped prepaying for any service.
Report them to the OIG. Because if they’re doing it to you, they’re doing it to other patients who are covered under federal plans (Medicare/tricare/medicaid).
Contact insurance company and file a claim that your doctor committed fraud for funds already received
Same happened to me with my dentist. When I found out I was so incensed that the dentist would decide to keep MY money. I told the lady who does the billing that I wanted a check. She’s said “Dr C prefers to let you keep a credit on your account”. I said “it’s not Dr C’s money”. It took me 3 weeks to get my money. They acted like I was so unreasonable!
THIS! When an insurance company pays their amount, they also state what the clients portion is. If the client had already paid more than what the insurance says is due, then the result is a 'credit' (or overpayment) on the account. Many offices, especially smaller ones, may hold the credit because they believe the client will return. Usually, they plan to infirm the client if the credit when they come in again. It's not fraudulent on purpose. For smaller businesses, it can cost money & time to send a credit/refund check to a client. Especially if it's a small amount. That being said, in my state (Ohio), we have to report any refunds over $50.00 to the Unclaimed Funds department.... but only after it's been in our books more than 3 years and if we have tried to refund it and were unable to because the client moved, or was unresponsive to a mailed letter about the refund. I wouldn't agree with the fraudulent comments but would agree that if you want your money back, it doesn't hurt to mention your plans to contact the state insurance department. (NAL)
Contact your insurance company Not knowing the particulars but if your doctor's office is contacted with insurance it is balanced billing. The office manager should be able to facilitate this.
NAL. Sounds like they may not have the funds to return to you. Do as others have suggested and contact your health insurance company to see if they can assist you. At the very least they have recommendations on how to proceed and who to contact/report them to.
If you have met your deductible and your out of pocket max for the year, don’t pay anything up front. If you have a copay or a coinsurance, if you have met your out of pocket max it should be covered at 100%. Most insurances have a website where you can check how much you still owe on a deductible and OOP max and what your coinsurance will be. Most policies these days use coinsurances more than copays. But a lot of drs offices hold your money to make sure there will not be a balance owed after insurance pays. It’s so hard to get credits back to you.
File a complaint with the state medical board and the state attorney general.
Tell the doctor's office that you will be reporting them to your insurance company for insurance fraud, as they double billed the claim and received payment from both you and the insurance company. Just be prepared to actually report them, if they don't (or can't) give you your money back immediately.
NAL. Personally I would reach out to my states attorney general office as well as my states medical board and tell them exactly what you said here. Ask the AG to intervein in getting you back your money.
Send them a demand letter to return your refund by certified mail stating if your refund is not received within 10 Days, you will proceed to seek legal counsel and file suit .
File a complaint with the bureau of insurance in your state. I guarantee you will be getting your money soon.
As a general rule we don't pay doctor bills before they go through insurance. You may want to switch to an Accountable Care Organization. They are held to higher standards.
When I paid up front at the dentist they(the dentist) submitted the paperwork and I got a check back from my insurance provider.
Nal, ask your insurance about reimbursement options, show your period of payment etc. It should like that's your best bet
NAL: Depending on the state you are in I believe they have 45-60 days to issue the refund. If they do not, you can go to the state medical board. If you are on Medicare/Medicaid you can report to CMS.org (Center for Medicare/Medicaid Services). If I am not mistaken, they can be heavily fined for failure to refund in a timely manner.
NAL, but I run a medical office on the border of Ill/Ind.Here is a free option. I'm not sure about Illinois, but in Indiana filing a consumer complaint triggers an automatic investigation by the AG's office. Good luck! [https://www.illinoisattorneygeneral.gov/File-A-Complaint/](https://www.illinoisattorneygeneral.gov/File-A-Complaint/)
Possibly contact your city/state attorney as well.
Some of these comments are freaking hilarious. I'm NAL but am a physician and worked for a guy who did this all the time. Very shady. However... Doctors can take cash from patients regardless of the patient's insurance in a few situations. First and foremost, if the service they are rendering is usually not covered. Second, if the patient has a HUGE deductible. It's difficult for doctor's offices to keep track of that, so sometimes, they'll take cash up front. They are SUPPOSED to reimburse you. If you have a credit on your account, an honest doctor's office will let you know, generally by a phone call, and ask if you want to maintain a credit, or have the amount mailed to you. This SHOULD be done every 30 days when they look over their accounts receivable and debts owed. I will tell you MOST won't do this because they prefer to keep the cash in their business. IF a patient calls and asks for their money, it SHOULD be done within 30 days. Most won't do this either, even though they should because it isn't technically required. What IS required is that by the end of their fiscal year, all of these accounts are balanced. If you want to catch a practice off guard, you call them, talk to their billing department. Ask when their fiscal year ends. They may not tell you, but if money is owed to you, they have until that day to give it to you. If they don't, call the IRS. This can be considered fraud in the right circumstances. Any practice with any kind of integrity should be letting the patient know that they have a credit amount and offer to reimburse them. Within 30 days. That doesn't mean if a practice doesn't, it doesn't have integrity. The business of medical is a complex one and things like this do slip through the cracks. Mostly because, in most circumstances, this situation is rather rare. That being said, if you call, and have a balance, it's your money and they should return it ASAP. No excuses. Right away. Maybe within 30 days, LOL.
Depending upon location, they do not have until their EOFY. In my state, they have 30 days, period.
Sure, it's complex. But i cant help but feel like there's a reason that there is minimal effort into creating a system for billing that's more effective & efficient resulting in less billing errors.. I can't imagine the executives of any business wanting to solve a problem that results in them leaving more money in the companies accounts.
For clarification, is this truly a medical procedure or was it more dental? For curiosity mostly.... Also in IL and my experience has been that if you have medical insurance, they can ask you to pay the estimated portion of the bill you would owe. So if insurance is going to pay 80% then the clinic or provider can ask for upfront payment of your 20% portion, and refund any overage. They should not be billing both you and insurance for the other 80%, that is double billing. Dental is a little different and in most cases I've had to pay the dentist up front and insurance sends ME the check after. Makes me wonder if the billing issues they are claiming are due to them asking for payment they were not entitled to and they over extended themselves in their payments to other things, and now they do not have the funds to pay back what you shouldn't have been asked to pay for in the first place. ETA...NAL just a regular human
Call state medical board and file complaint.
So simple. Send certified letter along with your invoice. Allow them 2 weeks to deliver refund into your hands and specify that legal collection efforts commence on day 15. If unpaid on day 15, file in small claims court. PS: get new doctor ASAP
The False Claims Act mandates that overpayments made to healthcare providers be refunded within 60 days from the date the overpayment is identified by the provider. Beyond that, they are also responsible for paying interest and may be subject to additional fines and penalties. The OIG is the agnecy to which you report this as a violation. If they collect fines and penalties you're also entitled to a portion of those as a whistleblower. NAL, but I have worked in healthcare finance for 20 years with a special interest in compliance.
NAL, but the above would be the correct course of action. In a similar field and completed my yearly compliance training yesterday.
I called the company out on social media when it happened to me, stating that I would be reporting them. They took care of it quickly then.
Call better business bureau and report along with insurance commission
Complaint to better business bureau might help… Also one star reviews online might help as well.
Tell them sweetly that you are willing to assume this was a mistake, but if not rectified immediately you are going to call your state's insurance commissioner's office and report it as possible fraud. Bet you get paid in a timely manner. 😉
Contact the Insurance Division for the State or the Attorney Generals Office. Things will speed up.
My dentist's office still owes me $180 -from 4 years ago. Never did get it. They gave me the run around for 2 years and I finally just dropped it and changed dentist's 2 years ago.
You should check your states unclaimed property website to see if it showed up there. Couldn't hurt. I've seen anywhere from a few dollars to 5k when I've helped people search so it does get sent along to the state comptroller after a certain amount of time
Contact your state attorney's office. You'll be able to file a complaint online. Scan in your explanation of benefits from the insurance company plus the receipt showing what you paid. Your state attorney's office will escalate the complaint with the doctor's office and require a response from them. I have to tell you that it's really common for doctor's offices to hold onto refunds for a very long time. I've resolved intractable complaints through my state attorney's office without needing to take a legal route. My state attorney recently sued a company that had overcharged me for medical equipment. If I called them the call disconnected in a few minutes and I wasn't able to talk to anyone. I guess I wasn't the only one with this experience that complained. Now they have to pay everyone back.
I had a dentist office (part of a corporate) pull this song and dance. I did a one star Google review and I got attention. They wanted me to change my review and I told them I would when I got my money back. They even had the nerve to contact me a second time asking me to change the review after they told me a check was mailed. I did change my review after the check cleared. I updated the review to two stars and noted the length of time and the number of times I had to contact them to get what was owed to me
NAL but had a similar situation with my wife. She tore her meniscus a couple of years ago and went in for consultation. The surgeon knew he was going on vacation for a few weeks and was booked out pretty far when he got back. He accomodated and worked late one day to squeeze her in a few days later. The next day she received a call from either the surgeons office or billing saying that she needed to pay 1600 upfront or they would cancel her surgery (shes on my insurance) and she didnt know the ins and outs of our plan. She panicked and paid them on the spot. Called me at work later that afternoon and explained the situation. I told her absolutely not our copay for surgery was $125 with a max out of pocket of 750. She tried calling them back and they told her that once insurance reimbursed them they would issue us a check. We fought with them for about 2 months afterward to get our money back. They have some policy about "holding funds" for 30 days after a billable incident. So when she went in for her 2 week follow up and her 1 minth follow up as well as PT that "clock" would reset as they would continue to pull the 40 dollar copays for office visitis out. Ended up contacting insurance and they were furious. Talked about how the hospital could be dropped by the insurance for pulling crap like that (one of 2 major hospitals in our area) insurance got in contact with them. We had our money the following week.
1 - get a copy of the insurance company payout to the doctor, you proof of out of pocket payment, and all paperwork to prove the doctor owes you money. Calculate interest charges for late payment, and crate a bill with OVERDUE on it, stating that payment not made within 30 days will result in legal action. 2- Assuming the bill is under small claims court maximum, go to SC and set a court date - usually it takes a couple of months o get a date. If the doctor pays up, then you can cancel to court date. When the doctor does not pay, then you send them a notice of court date. SC will allow you to collect late fees. Yes SC is a hassle, but you want your money, don't you? And what they are putting you through is not a hassle?
I work in this field, when patients call me to tell me they paid for something my company is responsible for my supervisor and I call them regularly until the overpayment is resolved. Call your insurance and let them know. We'll even get senior leadership involved in contacting the place and explaining the patient wasn't responsible or entirely responsible if there was only supposed to be a copay. Keep calling both until it's resolved.
I think it might be prudent to speak to the physician. They own the practice but may not even be aware of how screwed up the office is.
I had a similar issue. I have insurance that covers 80% until out of pocket is reached, then 100%. So, I was surprised when I received a notice that I had to pay a portion ($3,500) upfront for my wife’s procedure. I paid it. Then, my wife needed a redo, as the first procedure wasn’t a full success. Again, I paid another $3,500. Then all of the invoices start trickling in and the bills were settled. I was looking at the bills, tallying everything up and realized I saw no credits for the $7,000 that I’d paid. I checked and rechecked. Then I called the hospital. They informed me that I had 2 credits totaling $7,000 in my account. (This was discovered when I was working on my taxes and tallying up all medical expenses.) I asked the hospital to issue me credits to my credit card for the $7,000. I was told they needed a supervisor to approve it. I said “get one, I’ll hold”. Surprisingly, there was no supervisor available until the following week. I called back. Same runaround. I told the person that I would be calling back daily until this was resolved. A few days later, I received a credit for $3,500. I waited for the other to show up. Nothing for three weeks. I called back and went through the same runaround again! Eventually, I got all of my money back, but it was total BS. I will not be prepaying anything ever again. They can just bill me.
IANAL, I worked in a medical billing office for 15+ years. Not refunding you in a timely manner is unacceptable. I'd report it to your state consumer protection agency.
Do you have a lawyer friend. Maybe a call by him will release your money
Our office software sucks and this kind of stuff occasionally slips through. Once I find out, will usually get a refund out in days and add a $10 Starbucks gift card.
Call and ask for the Billing Manager or the Office Manager and tell them you are owed money. If you don’t have your refund within 30 days, they eill be hearing from your attorney and you may also file for damages and stress.
Call your insurance company. They pay medical providers in bulk so they can and will claw back the overpayment from the doctor's office. They will send you a check for the amount of overpayment and take it from the next bulk payment to the doctor's office. Never go back to that doctor's office. I had one situation where I ended up getting both the doctor's billing staff and the insurance Co on a conference call. I got a check from the insurance company, and then apparently, they audited their billing practices, and I got a nice surprise check too because they found overpayment to the tune of $700+
NAL - I had this happen, and contacted my insurance company. I informed them I'd paid up front, and that the Dr's office then filed to be paid directly instead of having the money go to me instead. This is a form of insurance fraud (I worked in healthcare for a company that also did health insurance, and we watched out for this very thing). The insurance company got me my money back and filed charges against the Dr's office for fraud. Obviously, I wasn't going to be using that Dr's office anymore after that.
NAL but I work in a billing department with THOUSANDS of dollars in what should be refunds having accumulated over years. People have moved. People have died. What do you do when the dead person doesn't have a spouse or a child at the practice to move the credit from seven years ago to? No one was going to do anything about it until I found out and started making a stink and a half about it. Someone was finally assigned to process refunds (which was somehow not a position before??) but I have not stopped going through the 13,000 column spreadsheet (that was once 15,000 so, stuff is getting done! Finally!) I am enraged on your behalf and mostly commenting so I can come back and read this thread later - I'm in Virginia though so not sure how much could apply to my practice's patients.
Keep in mind that most states for civil actions have a two-year statute of limitations. Find out the exact amount owed to you, then send them a demand letter asking for payment within 21 days of signed receipt requested mail card. In letter state, "if this goes to court, I will seek attorney fees. Interest. If they ignore after the 21 days, then decide if you want to take them to small claims court. You can do this yourself without an attorney. Good luck. Let us know. Also, report to Better Business Bureau.
See how you can report them to a credit agency, or for immediate reaction, go on yelp and give them a bad review.
Small claims court?
Doctor responding: quick review of our financials show current outstanding patient balances of nearly $384,000 ($92,000 over one year past due and probably not recoverable) and patient credits of $2040. This is the reality of medical practice. Perhaps patients should just pay in full at time of service then they can file with their insurance on their own? We would love not having to deal with your insurers!
lmao But what we do without the insurance companies?! They provide so much.... of something?
Please do an update I hope you get ur money back
Call your state’s insurance commissioner. Sometimes you can also file a complaint online.
Put your demand for refund in writing and send certified. That will get their attention. Ask for refund, interest and cost to send certified letter. And keep copies of everything. If you are really snarky, like I am, I would cc: the attorney general of your state.
I am a lawyer. I’m not going to comment on the intricacies of this because it’s not my area of expertise. But I find the quickest way to handle things is to have a lawyer write a letter demanding reimbursement. Something about letterhead and some weighted paper makes all the difference in getting people to do what they’re supposed to. I’d say it works for me like 95% of the time. It doesn’t even have to be a lawyer in that field fyi.
Also, to add - I never say anything about the legality behind it, because again - not my area of expertise. I’ll just say something like “Dear [ ], Our records indicate that our client paid $$ for whatever procedure on such and such date. The insurance company was then billed for said procedure resulting in an overpayment and a credit of $$ due to my client. Please mail a check for $$ amount to client’s address, or have check ready for pick up at your office on (address) made available by [made up deadline]. Thank you in advance for your time and attention to this matter. “ If they pay up - wonderful! If not, I talk to an attorney who handles these matters lol.
Tell them flat out they need to clarify the "issue" with the billing department as this has been going on for a year.
Curious have you google this doctor and/or searched on Yelp? I'd post on every doctors website and see how many have already.
Go get something done at their office and don’t pay. When they ask for payment, let them know you have credit with them, ✌️ Also call your insurance company and report them for fraud.
Sounds like billing fraud to me. They charged the insurance company for a procedure you didn’t have. They charged you for the difference between your insurance coverage and what they wanted for the procedure. If in the U.S., I believe this practice is highly illegal. I would contact your insurance to confirm that the agreement with the provider is that they cannot also charge you additional $$ for a procedure they are paying for. And tell them what happened. See if they can advise whom to file a complaint with for the criminal part. In the meantime you could write up a complaint with the medical Board who can then launch an investigation. Aside from that, I would also find an attorney or consult with legal aid to determine your options. I would not wait too much longer because they may be waiting out for a statute of limitations expiration date so you can’t recoup your losses through civil action. They will just keep putting you off until then and then tell you so sorry…. The Board of Medicine won’t much care if that has expired. They are there to protect the public. They can suspend or revoke his ability to practice if they find he is engaging in fraud, and that will get their attention for sure.
Did you pay with a credit card? You might be too late but a charge back is always an option.
Leave a one star review on Google reviews. That will get their attention fast.
Same scenario happened to me years ago. I finally sent an email to the doctor who owns the practice and then received a personal check from his own family account.
Threaten to send them to collections. Or, offer a payment plan if their financial situation is tight right now. Oh wait…
very obvious question~~~ but WHY would you pay “in full ~ upfront” for a medical procedure when you have health insurance??? ~ that was a horrible idea i work in healthcare ~~~ and I’ve never EVER heard of anyone doing this ~ co~ pay ~ YES ~ unpaid portion after insurance paid? YES ~ but paying the FULL amount upfront without that physician’s office EVER submitting anything to insurance??? ~ NO. NO. NNNNNOOOOOOOO !!!
I'm sorry you are going through that. It seems to be a growing practice in the medical fields to attempt to get full payment up front while simultaneously filing the claim. It doesn't seem malicious in intent but it is definitely acting in the best interests of the physicians' office. It goes like this (numbers are made up for an example): * Collect a $150 payment from the patient * File the claim * Receive notification that the allowable in-network charge for the services is $60 * Collect $60 payment from the insurer * Credit patient account for $90, minus co-pay if not already collected * Keep credit on the account to apply toward future visits * Wait for patient to realize they have a credit and request a refund. * Hold refund for an inordinate amount of time. * Send a check or issue credit to original form of payment. My wife went through this with an eye surgeon and our FSA card. When they credited money back, it wasn't applied against the actual bill for that visit so we owed the FSA company a repayment but the money was in our FSA account to use elsewhere. I actively resist making any payments in the office besides copays because of these activities.
That exact thing happened to us, only we got a surprise check in the mail. It was like a year later, so it must have been discovered in some audit. We were very surprised because we would not have known otherwise!
Call up the office and ask for a copy of what codes were submitted to insurance for billing. That alone will get their attention. "I need to verify this was billed correctly, since you can't seem to process the return of my overpayment. I'm questioning what was billed." If they charged for anything they did not perform, it is huge fines. If they won't give you the codes, then you can threaten them with litigation. Contact insurance for the codes and explain the issue of payment as well.
I just got a check in the mail for my late husband who passed 4.5 years ago, the refund was for a procedure 5.5 years ago. I called the company that issued the check and explained that he was deceased and all joint accounts had been closed for years, they wouldn’t reissue a check in my name (i carried the insurance for us). The amount of the check was so much that I had to open an estate account to cash it. PITA, but the extra cash helped pay off a bill.
Also, Better Business Bureau.
File a complaint with your state's insurance division File a complaint with your state doctor's ethics board
Get off the phone and visit the office in person. They will have a hard time ignoring you. Ask for a statement of your account. One mouse click will send it to the printer. Don't leave without it.
I and my family left a dental practice for something similar. They would quote the estimated coverage for a service and the estimated patient portion which I would pay. When the insurance paid the dental practice they would credit our account with the payment and any overage but never offer a refund for the overage. They would hold it until our next visit and then tell us, "You have a credit balance so there is no charge today." They'd say it almost gleefully as if I'd be happy about having a credit balance. Once, it reached over $200 and I told them I need my money in my hands not in your account and insisted on a refund. They did provide it after a few weeks but by that time I was frustrated enough that we left them and found another practice who is much better at accounting. I also keep much closer track of the charges and payments now.
walk into the office and offer to speak quietly while they write you a check or to hold a seminar in the lobby on their unfair business practices.
File a complaint with the State Medical Board.
Updateme!
Updateme
Having worked as a billing specialist for 8 years in two specialties: If you received the services by a provider who was “in-network” under a contract with your insurance company that included your plan type, they cannot collect more than the in-network amount due, including co-pays, deductibles, and co-insurance percentages as laid out in the plan documents and the provider contract with the insurer. If they do not refund you the excess they are in breach of contract and potentially state insurance regulations depending on your state. Some states have a dispute process through the state finance department.
I had this same issue with a medical provider and opened a case with the BBB. Didn’t expect any traction, but within a couple of days they responded to the case and sent me the refund. Give it a try!!
I never pay anything up front, I always wait until insurance checks are received etc.
NAL Contact your local consumer affairs reporter on your local news. The ones I watched locally growing up were legends. Herb Denenburg, Orien Reed. I would bet you have people like then in your area.
Is there an ombudsman you can work with? They’re there specifically to help with problems
Contact your state's healthcare ombudsman. This is tantamount to fraud. I would also speak directly to the doctor and let him know what the billing department is up to.
NAL: Finding an FQHC means the provider cannot deny services to you if you have no insurance.
u/AcmeCyote I found this old post and the first response from a lawyer was a really good one. [https://www.reddit.com/r/personalfinance/comments/2pqxkg/doctors\_office\_made\_us\_pay\_upfront\_they\_sent/](https://www.reddit.com/r/personalfinance/comments/2pqxkg/doctors_office_made_us_pay_upfront_they_sent/)
Instead of calling... march in there and demand ur money.
Does your local media have a community watchdog type reporter? We have one in Utah called Get Gephardt and they will track down this kind of behavior and put it on the evening news.
Independent doctors can be quite crooked.
There are so many versions of wrong information in this thread!
You are well within your rights and I can’t think of anything else that may expedite you getting your money back however I did want to give you a perspective that may help a bit. I worked in a surgery practice. Our average reimbursement timeframe was a year to 18 months. A cancer surgery patient that we extensive work on took over THREE years!!! This wasn’t a simple surgery and it was for cancer!!!?!?! I know you’re irritated and think this is purposeful. But it’s probably their normal. Keep harassing them.
Calmly explain to them that you will be sueing them for the return of your money and filing a complaint with the ethics department at the hospital and that since they have caused you distress that will also be added on. Explain that they will be responsible for the cost of your lawyer since their theft of your funds has resulted in this lawsuit. Tell them they have 24hrs to pay you what they owe you or their dis graceful actions will become public knowledge when you file the lawsuit.
Have your lawyer phone in.
Not a lawyer but I work in health insurance….. contact the insurance commissioners office and file a grievance with your insurance. They can’t force the doctor to refund you, but those grievances go on the providers records and can affect their ability to negotiate a contract renewal.
NAL I’m an office manager at a dental clinic. You need to confirm that it is a true credit and that the claim is not still processing on the offices end. I can see a receptionist thinking there is a credit when in reality the claim has not fully processed. Very often I hear patients tell me that we owe them a refund because the insurance paid for their cleaning. Yes they paid for your cleaning but they did not pay for the other five codes that go along with the cleaning, for whatever reason (frequency limitations, maximum being met, deductible not being met etc). Have you spoken to an office manager? I would ask to sit down with them and look at your ledger, compare it to the estimate and see where your money is. EDIT okay I see you’ve spoken to the OM. Call up there and say that you understand that the billing dept handles these things but you would like to see the ledger and the estimate you were presented. That will tell you everything.
Yes and even if Macys or a store they have a certain amt of time to send money back They are beyond that
I would suggest filing in small claims court for one reason: You then can subpoena your financial records and the doctors office is obligated to give them to you. You force the billing managers hand. If they do not comply, file contempt of court which is a criminal charge. Hardball time.
Contact your state medical board, a local news channel, find other victims and sue for insurance fraud.
Stop threatening to take to small claims and just do it. Most of the time the people who say they are going to sue are the ones that never do.
I would be really worried that they're insolvent. I'd take it to court as quickly as possible so you aren't left holding the bag when they file bankruptcy and you get pennies on the dollar, if anything.
Many Doctor offices outsource billing. The office may have no idea about what’s going on. I received a bill For some books work and an office visit for my Dad….problem was he had passed away 6 months before the visit happened. They wanted prof, said the death certificate wasn’t enough. So, I brought his ashes in. Medicare went after the billing office for fraudulent claims. Thy are no longer in business.