Fraudulent Healthcare Charge

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Dec 19, 2014
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In my case they legally have to wave copay as I have QMB which means I'm a Qualified Medicare benificary which gives me 100% coverage for Medicade as well and I also receive extra help and this is hard for them to grasp they may only charge me for a small copay for Medicade 3.50 nothing above the approved amount and because it's such a different type of coverage they constantly try to bill for the 15% by law over the approved amount and they keep saying they don't take Medicade but it doesn't make a difference if they accept Medicare these are there rules! It's taken me year's to figure it out so I don't expect them to be up to code as you say
Apples and oranges...

With Medicare, a provider can either be
a) Medicare with assignment
b) Medicare without assignment
c) non-participant with Medicare.

A provider who accepts assignment with Medicare, then they agree to accept the Medicare approved charge. For example, if the provider bills $1000 dollars for a service, and Medicare's allowable is $50, then the provider may only collect $50 and cannot collect the difference of $950. As a patient, you are still responsible for the deductible and co-insurance

If a provider accepts Medicare WITHOUT assignment, they are allowed to bill up to a 15% premium on the Medicare allowable. In the above example, they are allowed to bill up to $57.50, though that may be further limited by state regulations. A provider who does not take assignment, is also allowed to bill you upfront and require you to file reimbursement from Medicare using form CMS 1490S.

So, is your provider accepting Medicare with or without assignment?

Medicaid has nothing to with the equation as in your situation, Medicaid would be secondary, and would what Medicare doesn't pay up to the maximum allowable by Medicare. If the provider does not take Medicaid then you are still responsible for the amount up to what Medicare doesn't cover, up to either the Medicare allowable if your provider takes assignment or the allowable + 15% if your provider doesn't take assignment.

There is also a 3rd scenario (scenario c), where a provider opts-out of Medicare. In this scenario, the provider can charge any amount and is not subjective to Medicare allowable rates, but this is a very unusual and rare situation.

The reason I say post #20 is irrelevant to the original post, is that post #19 has nothing to do with coding and the legality of billing 2 "visits"

Insurance is very complex and there are too many scenarios to generalize. Often times, these type of posts have much missing background information, but I hope the above explanation will at least provide insight for the OP in post #19
 
Nov 11, 2019
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Hello Everyone. Just wanted to provide an update. Some time after my last post, my account was sent to a collection agency. I sent a letter to the collection agency stating that the account was under dispute and they backed off. I sent another letter to the office manager berating her for sending the account to collections without first answering any of my prior letters. I received a lengthy phone message saying that my account was now in the hands of the coding manager. To date, I have heard nothing since. After reading all of the comments, I believe the fault (at least in my situation) lies with Amita's inept handling of a wellness visit. I think that most people think of a wellness visit as a new term for their annual physical, where everything is discussed. Amita needs to employ someone to meet with all patients, prior to the beginning of their wellness visit, and explain everything that is included and not included. Having said that, I still believe that a wellness visit is a huge scam foisted on an unsuspecting public. I will keep you posted.
 
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jsn55

Verified Member
Dec 26, 2014
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WOW! I've been away, so this is the first chance I've had to catch up. Thank you to everyone who has responded with advice. I appreciate all of it. To clarify, I did not make two separate visits to the physician on April 25. I acknowledge anger in addressing the complaint as "fraudulent" and "bogus". I am attempting to remedy that in ongoing correspondence. First, in answer to someone's advice, I have gone back to the Office Manager in two letters, both of which have gone unanswered. Second, I truly fail to see why a less than 10-second request to a nurse to add another panel to my bloodwork would constitute an "office visit". Furthermore, that panel would have been added had the physician correctly diagnosed my issue in the first place when I saw her 9 months prior. That, in essence, is what I am protesting. Amita, and others like them, have turned physicians into unscrupulous, slimy salesmen in an attempt to please their shareholders!
Your last sentence is exactly what's going on. A single practitioner is not going to charge you a separate office visit for discussing something not covered under your "wellness" exam. For starters, how would YOU know what was acceptable and what was going to incur an additional charge? The big, organized clinics and monster medical offices have people (just like the airlines) who sit around thinking up ways to increase the bottom line. They instruct the office staff just how to do this, and if said staff wants to continue to be employed, staff will follow orders. While the docs probably were briefed on this at one point, in my experience doctors are far more interested in their patients' health than charging extra because they can. They probably aren't even aware that this is going on. Chances are 80% of the patients just pay the co-pay and don't say a word. I applaud you for taking a stand here.
 
Nov 11, 2019
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SUCCESS! Last week I received a phone message from the Office Manager of Amita saying that the charge I was disputing had been erased and my account now had a zero balance. In a way, they still won since they collected a fee for an office visit from my insurance company. In any event, I feel vindicated. Thank you very much to everyone who took the time to respond to my issue to offer advice, support or even constructive criticism. I wish everyone well!
 

jsn55

Verified Member
Dec 26, 2014
9,248
10,031
113
San Francisco
SUCCESS! Last week I received a phone message from the Office Manager of Amita saying that the charge I was disputing had been erased and my account now had a zero balance. In a way, they still won since they collected a fee for an office visit from my insurance company. In any event, I feel vindicated. Thank you very much to everyone who took the time to respond to my issue to offer advice, support or even constructive criticism. I wish everyone well!
Well done! Thanks so much for letting us know.
 
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Dec 19, 2014
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SUCCESS! Last week I received a phone message from the Office Manager of Amita saying that the charge I was disputing had been erased and my account now had a zero balance. In a way, they still won since they collected a fee for an office visit from my insurance company. In any event, I feel vindicated. Thank you very much to everyone who took the time to respond to my issue to offer advice, support or even constructive criticism. I wish everyone well!
I'm glad that you "won" your case, but as someone who has extensive knowledge of medical coding, they essentially waived your charge to make it go away. They coded it correctly, and in your situation they just wrote off the charges.

I realize that you will always believe the office did nothing wrong, but why shouldn't they have been paid by the insurance company? After all they evaluated you.

Constructive feedback: As you have a new child with at least 20+ well child visits and probably 3X as many "sick" visits" in the next 18 years, know that a "wellness" exam has a very specific scope. When you go to a well exam and want to have a new problem evaluated, or have significant changes in chronic problems, it will be billed a second visit and this can be done legally.
 
Mar 3, 2017
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I had the same thing happen to me last year: at a wellness visit I asked my doctor a follow-up question about issues that affect my health. There was no additional exam, no referrals, no prescriptions, but that single question asked within the parameters of a well-check triggered an office visit charge for the same appointment that was otherwise considered a well check that was covered by insurance. I fought it with the office and billing, and they eventually took the charge off. That I even had to experience that was ridiculous.
 
Dec 19, 2014
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Without knowing specific details about your case, it is impossible to determine if your visit was coded correctly or not. Since this forum cannot provide professional or legal advice, you will need to consult a professional coder or work with a patient advocate to determine whether you were appropriately billed.

However, I will provide a few general comments...
- You are alleging "fraudulent healthcare charge." That is a very strong allegation, and it may or may not be true. A more likely scenario is a) the charges are legitimate, or b) an error was made. To successfully advocate your case moving forward, I would avoid using the terms "fraud" as that will make it very difficult to negotiate.

- There are "preventative" codes which are used for physical and wellness exam and E&M codes (evaluation and management) which are used for "acute visits." Typically, health plans will cover preventative codes without any co-pays, because the health care plans encourage preventative medicine.

Wellness and physical exams are just that. They are there to address preventative medical issues. A physical exam does NOT address any acute issues or chronic medical issues that require active management. If any acute issues are addressed or if active chronic medical management is performed, the provider may add a modified -25 to an E&M code and bill both. This is permitted and legal.

For example... you go in for a physical exam, but during the exam go "hey doc, I think I have a sinus infection." If the sinus infection is actively managed, the provider will bill a preventative code 993XX and a E&M code 992XX + modifier -25. The patient will be responsible for both charges. Where it gets dicey is that the E&M service must have "active" management. Since many patients have chronic illnesses such as asthma or hypertension, if the chronic illnesses are stable and no change in management is needed, it would be incorporated into the prevention code.

So, if you went in for a wellness visit, had another medical issue addressed, and there was active management (ie medication dose adjusted, medications changed, additional testing ordered), the separate E&M code is valid.

- Finally, in the medical field it is not as simple as "waiving" a co-pay or "waiving" a visit. Depending on the insurance contracts, "waiving" co-pays can be considered fraud itself. So, medical billing is focused on getting it right, and if they are right, it is highly unlikely that the charges will be waived.
That's what my Doc's office does; billing for both. Wellness visit is no co-pay; but because she orders labs and renewal of my Rx for synthroid which I have been taking for 30 years no change , and no other meds --- I now owe copay for that issue. The wellness visit is an assessment of 'did you fall, do you fall', a very gross mini mental status exam, and her writing down answers to some questions. For some, this is a valuable experience, to see if there are massive deficits and problems for daily living. I don't know what to say to my insurance... will they refuse claims if I refuse it?
Yes, it's not fraud. It's the way their 'rules' are.
 
Jul 7, 2018
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So the real problem I see is this is an issue caused by insurance rules. The Dr. codes what they do within the ICD codes that are needed to process a claim. Depending on how those codes are going to be paid by the insurance (and they all adjudicate differently based on the different plans) you may or may not have co-pays or out-of-pocket expenses.