Fraudulent Healthcare Charge

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Nov 11, 2019
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#1
On April 25, 2019, I visited a physician at Amita Health in Woodridge for a wellness visit. During that visit, I updated the physician regarding a problem she had treated me for. The treatment she prescribed, as well as her diagnosis, was ultimately wrong and corrected by a visit to another doctor. Without commenting on her treatment, I simply gave her the information so she would have a completed health history for me. On June 1, 2019, I received a bill from Amita. On it there was a charge for the wellness visit on April 25, for which there was no charge or co-pay due from me. There was another charge for an office visit, on the same day as the wellness visit, and Amita was requiring that I owed a $30 co-pay for this office visit. I telephoned the Billing Department, and was referred to the Office Manager for the Woodridge site. She indicated that the April 25 office visit charge was for the problem I noted above. I explained to her that there was no treatment involved and that I was only imparting information to the doctor. She said she would review the charge and get back to me. To date, I have not had any communication from her, either written or telephonic. After two weeks of not hearing back from the Office Manager, I consulted Elliot Advocacy's website and got the names for the Regional Manager and Regional Medical Director of Amita. I sent them a letter explaining the issue and asking for a response. Again, to date I have not received any communication from either gentleman. On November 2, I received a notice from a collection agency that the amount claimed as owing by me ($30.00) was now in collections. As instructed in their notice, I sent them a letter stating that the amount was in fact not in arrears, but was in dispute. I was going to send another letter, this time to the superior of the regional directors, but am not able to locate names. I am asking for advice on how to proceed.
 
Nov 11, 2019
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#3
The bill was for a wellness visit, which my insurance covers in full, and an office visit on the same day. The co-pay is for the office visit. I did speak with the Office Manager and she promised to look into it and get back to me. She never did.
 
Nov 20, 2015
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#4
My advice (as a primary care physician) is to go back through the office or billing manager, and keep working with them until you are sure they can't or won't help you any more. This is the level where you're most likely to get help. I would phone again, then immediately follow up with an email summarizing your phone conversation. If it's worth it to you, you can actually meet with the manager in person. If none of this works, then escalate to higher level managers again via email.

It sounds as though you have a good case here. I wouldn't use the word "fraudulent" in any of your communications, it implies that the organization is intentionally trying to deceive you. Referring to the dispute as an "error" or "mistake"will win you more cooperation from the staff.
 
Jul 30, 2018
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#5
When writing the company contacts it is important to write them one at a time, starting with the first one listed, waiting a week, then writing to the next one if you receive no response. Simultaneously emailing all of the contacts at the same time can result in you letters going to spam and thus no response.
 
Likes: jsn55

mmb

Verified Member
Jan 20, 2015
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#6
Have you called the doctors office and told them they double billed you? So you usually have a co-pay for a wellness visit?!(I know I do because it’s an office visit)
The once/year wellness visit is usually covered at no cost to the patient, per most insurance companies, including Medicare.
She said she doesn’t have a co-pay for a wellness visit and that was all there was to her visit that day.
It sounds like the office is saying she returned the same day for another’s visit, for which she would owe the co-pay. That, in itself, is highly doubtful.
 
Jan 6, 2015
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#7
The challenge here, I think, will be this:

"I simply gave her (the doctor on 2nd visit) the information so she would have a completed health history for me"​

If you actually met with the doctor, then you can be charged for an office visit. Hopefully they will waive this for you . . .
 
Likes: Neil Maley

mmb

Verified Member
Jan 20, 2015
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#8
The challenge here, I think, will be this:

"I simply gave her (the doctor on 2nd visit) the information so she would have a completed health history for me"​

If you actually met with the doctor, then you can be charged for an office visit. Hopefully they will waive this for you . . .
@snooze56 reported in first post

On June 1, 2019, I received a bill from Amita. On it there was a charge for the wellness visit on April 25, for which there was no charge or co-pay due from me. There was another charge for an office visit, on the same day as the wellness visit, and Amita was requiring that I owed a $30 co-pay for this office visit.

Clearly, Amita is charging for a 2nd visit on the same day and that is a mistake. OP had one office visit which was a wellness visit. no co-pay required.

Unless OP had two wellness visits within one year, she owes no co-pay. If she scheduled two wellness visits within one year she does owe for an office visit. The wellness visits MUST be a full year apart.
 
Likes: Algebralovr
Dec 19, 2014
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#9
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.
 
Dec 19, 2014
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#10
@snooze56 reported in first post

On June 1, 2019, I received a bill from Amita. On it there was a charge for the wellness visit on April 25, for which there was no charge or co-pay due from me. There was another charge for an office visit, on the same day as the wellness visit, and Amita was requiring that I owed a $30 co-pay for this office visit.

Clearly, Amita is charging for a 2nd visit on the same day and that is a mistake. OP had one office visit which was a wellness visit. no co-pay required.

Unless OP had two wellness visits within one year, she owes no co-pay. If she scheduled two wellness visits within one year she does owe for an office visit. The wellness visits MUST be a full year apart.
Charging for a preventative visit (993XX) and an acute visit (992XX) is permitted under terms of all insurance contracts, but specific criteria have to be met (medical necessity and documentation). The only way to determine if this was valid or not, is to review the documentation and that is outside of the role of the advocates on elliott.org.

Insurance will not pay for 2 wellness visits within 365 days, so if a 2nd wellness visit is scheduled short of the 365 day interval, insurance will reject the claim.
 

Dwayne Coward

Administrator
Staff Member
Director
Apr 13, 2016
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#11
On April 25, 2019, I visited a physician at Amita Health in Woodridge for a wellness visit. During that visit, I updated the physician regarding a problem she had treated me for. The treatment she prescribed, as well as her diagnosis, was ultimately wrong and corrected by a visit to another doctor. Without commenting on her treatment, I simply gave her the information so she would have a completed health history for me. On June 1, 2019, I received a bill from Amita. On it there was a charge for the wellness visit on April 25, for which there was no charge or co-pay due from me. There was another charge for an office visit, on the same day as the wellness visit, and Amita was requiring that I owed a $30 co-pay for this office visit. I telephoned the Billing Department, and was referred to the Office Manager for the Woodridge site. She indicated that the April 25 office visit charge was for the problem I noted above. I explained to her that there was no treatment involved and that I was only imparting information to the doctor. She said she would review the charge and get back to me. To date, I have not had any communication from her, either written or telephonic. After two weeks of not hearing back from the Office Manager, I consulted Elliot Advocacy's website and got the names for the Regional Manager and Regional Medical Director of Amita. I sent them a letter explaining the issue and asking for a response. Again, to date I have not received any communication from either gentleman. On November 2, I received a notice from a collection agency that the amount claimed as owing by me ($30.00) was now in collections. As instructed in their notice, I sent them a letter stating that the amount was in fact not in arrears, but was in dispute. I was going to send another letter, this time to the superior of the regional directors, but am not able to locate names. I am asking for advice on how to proceed.
Snooze56, in your help request you submitted, you had an additional detail about lab work your doctor ordered in relation to this that may be crucial to your case and the advice our members can provide.
 

Dwayne Coward

Administrator
Staff Member
Director
Apr 13, 2016
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#13
Did the dr. order lab work based on your second visit? If so- that would seem to be why you were charged for another visit and important piece of information we needed.
Neil, I believe there was only one visit. I ran into this a couple of years ago myself. In my case, I bought up something that isn't covered by my insurance's wellness visit, and since my doctor acted on it (ordered test), the insurance considered it an office visit.
 

mmb

Verified Member
Jan 20, 2015
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#14
Neil, I believe there was only one visit. I ran into this a couple of years ago myself. In my case, I bought up something that isn't covered by my insurance's wellness visit, and since my doctor acted on it (ordered test), the insurance considered it an office visit.
My doctor (who performed the wellness exam) refused to discuss any other issues at the wellness exam and I was forced to schedule another appointment to deal with those issues.
Was clearly a good idea since we all understood the situation.
Now that I’m on Medicare, my PCP is miraculously able to attend to all of my issues during the wellness exam. :)
 
Jul 27, 2018
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#15
The rules for what is and is not included in an annual wellness visit are precise. If something outside of the covered items of a wellness visit is done, a separate charge may be generated. However, any elements of the second visit that were also in the wellness visit may not be charged for in the second visit. For instance, if the wellness visit includes a complete history, then any history element in the second visit is not allowed, lowering the visit level and associated charge for the second visit. Coding a second visit on the same day as a wellness visit is very tricky and subject to error.

I recommend that the charging doctor's office be requested to review the coding of the second visit to see if the charge level was correct. If that review is unacceptable to you, ask the insurance company to review the records for a possible coding error. I would also get a copy of that day's records, both wellness and second visit, to see if what was written as done was actually done. Electronic records can generate a lot of undone things as having been done with just an errant click on a checkoff box. The doctor's office must provide you the records on your written request.

Note that if your insurance has the same $30 copayment for every level of visit, there will be no point in doing anything other than changing doctors.
 
Likes: VoR61
Nov 11, 2019
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#16
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!
 
Dec 19, 2014
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#18
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!
 
Dec 19, 2014
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#19
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!
Admin, post #18 was posted in error. Hit the Post button before I typed anything

@snooze56
Your latest reply actually answers the question why you were charged the E&M code (2nd visit)

1) You do not need to be seen twice to get billed 2 "visits." This is allowed by coding standards.
2) If the blood work that was added does not fit into the allowed criteria for physical exam, it HAS to be coded as a separate visit.
3) " 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 is a lot of speculation, and 9 months is a long time for things to change.
4) "Amita, and others like them, have turned physicians into unscrupulous, slimy salesmen in an attempt to please their shareholders!" I would avoid any of these statements in your communications.

Based on what you posted, the coding appears legitimate and correct. The physicians office cannot overturn a correctly coded visit. Undercoding is as much insurance fraud as is overcoding.

The err that was made, was that the health care team should have advised you before the blood draw, that the blood test ordered is not covered under the physical exam code, and that you will be billed for a separate visit for that specific draw. That is a communication and customer service issue, but again, legally, it cannot be waived.
 
Nov 24, 2019
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#20
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