Health Insurance Question - Possible Fraud?

[matt819]

Here's a question for you. I went to a provider, was given a bill on leaving, and paid by check - $130. No problem.

I then submitted a claim to the insurance company. I didn't expect any reimbursement, but I wanted the amount to be directed to my deductible. I had to send the form to the provider to complete, and they submitted it to the insurance company. I just got the insurance company's statement, which shows the amount charged to be $270, with an allowed amount of $125, that is, the amount I would otherwise have had to pay. The insurance company paid nothing due to my deductible, and, as noted, I actually paid $130.

Since I was billed (and paid) $130, shouldn't that have been the amount submitted by the provider to the insurance company? Granted, the provider didn't receive any money from the insurance company, so I'm not sure it's fraud. It seems highly unethical to bill me $130 and then bill the insurance company $270, but is it fraud?

Thoughts? Worth reporting to. . . well, to whom would this be reported?

Thanks.

[cbayer]

1. Doctors, hospitals and other providers have their own fee schedules

and the amounts are almost always much higher than what they actually receive from any payor.

What most likely happened is that the office knew that the allowable amount (the amount that your insurance company said they were willing to pay) was $130. It looks like they may have made a $5 error, but that could be a simple coding issue. And if they knew that you hadn't met your deductible, they charged you that amount.

But, when they sent the bill, they sent the amount that they use in their own fee schedule. They knew they wouldn't get that, but that's SOP, as each payor has a different payment schedule.

Nothing fraudulent about it, IMHO, but they do owe you $5.