Need specific next-step help - CT
I am quite sure our opthamologist's billing clerk is lying about our bills. My husband saw the dr. in August, 2005, for a routine eye exam. We got the first bill in January, 2006: Exam (established patient): $150; Refraction (est. patient): $100. My husband had paid $30 at the visit, as a co-pay, since he was not sure if our insurance covered routine eye exams (it does not). Amount due and noted PAST DUE: $220.
I called about the amount and the lateness of the bill. The billing clerk called back and said that since our insurance company did not pay for the refraction, they had written off the $100 charge, so we owed $120. She also said this was not the first bill, it was the third; one had been sent to us in November and two in December. I dispute this, but even if it were true, a first bill in November for an August 9th eye exam is VERY LATE.
My husband and I are both CPAs (for a combined 50+ years) and have auditors instincts. When I told him about this conversation, he said something seemed wrong about the whole thing. I agreed. I was sure I had not received a previous bill, and also that I had not received an Explanation of Benefits showing the claim had been denied. To be certain, I looked at all our claims on-line and spoke to two different reps at the insurance company, and no claim had ever been submitted by the opthamologist for this visit. The reps told me that if a claim had been submitted, it would show up and an EOB would have been mailed to us and to the doctor, regardless of the approval or denial of the claim.
A week later I called the billing clerk again and asked why there was no record of a claim having been submitted. I also asked her why the $100 for the refraction was not taken off the bill, but was only taken off when I phoned her. The bill as we received it, with "PAST DUE", could be intimidating. I can see very easily how someone might get frightened by the PAST DUE, or not be able to phone the office during working hours to discuss it; in other words, PAY IT without questioning it.
The clerk began explaining about refraction and that my insurance company doesn't pay for it. I understand refraction, and I understand that my insurance company doesn't pay for it. What I needed from her was proof that she ever submitted a claim. She asked me why I needed that since the insurance company wouldn't pay for it anyway. I said I thought something very odd was going on with the lateness of the bills, the high charges, and the verbal reference to insurance company denying the refraction -- when the insurance company had never been billed.
The clerk was not my best friend by then. She called back the next day to say she had wired the claim to the insurance company, and it had been denied, it was somewhere in her notes, or they called her, not sure. I checked with the insurance reps who told me, again, that any claim would show up, and any denial would have been sent to me in an EOB. Their records showed nothing. I checked with the insurance company who used to handle the vision claims prior to 2004, just to be sure, and they had no claims.
Our suspisions are that the opthamologist's billing is purposely late so that by the time a patient gets the bill the patient will assume he has misplaced previous bills, is in danger of being turned over to a collection agency, is intimidated and just pays it - fast. When I called about the high charges, the billing clerk immediately said they were writing off the $100 refraction fee because our insurance company didn't cover that. While this is true - our insurance company doesn't pay for any portion of the routine eye exam- the clerk never submitted the claim to insurance, though she says she did. Her saying they wrote it off because insurance didn't pay it - how did she know they didn't pay it if she had never submitted a claim? Why would she say she had submitted it?
The clerk told me about the $100 write-off so fast, it came across as a prepared remark to make to patients who called about the high charge for the exam and the additional charge for the refraction.
My husband and I think there is a pattern of delayed bills, false claims about submissions to insurance companies, and high charges. The payoff to the doctor (or the clerk) would be from patients who get frightened by the "past due" and pay the entire (padded) bill quickly, before they get into trouble with a creditor.
One last oddity: our son saw the same doctor in November, 2005, for a routine eye exam. But our son has type 1 diabetes, so his eye exams ARE covered by insurance. I asked the clerk if she had submitted his claim properly - as medically necessary due to diabetes. She "looked it up" and said yes, she had. The insurance company had not received any claims for my son. This really made no sense since the visit was covered. Later she told me she submitted it but it was rejected because his coverage ended in 2004. (Reason: our son went onto COBRA in 2004 and got a new insurance card with a new ID # - she was using the old number.) The question is: if she really had submitted the claim when she said she did, and it bounced back, we would have/ should have received a bill from the doctor's office asking for payment or new insurance information. All the other doctors who saw our son in that same week in November (home from college, he saw dentist, dr., eye dr., endocrinolgist all in 1 week) submitted claims which were paid, meaning they all had the correct ID#, my son had his card, etc.
This seems to support the idea that the office is delaying sending out bills, and the clerk automatically says she submitted claims to insurance companies when she actually hasn't. Either she is incredibly inefficient (but has worked for the dr. for 15 years) or is lying.
So -- the insurance company has begun an inquiry about my husband's supposed claim, but the only evidence is the lack of evidence. We think something is rotten here. Do we go to the State of CT - licensing??? Insurance fraud?? What is the next best step?
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Originally Posted by Bill West
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