a tale of two doctors

April 3rd, 2008

A Tale of Two Doctors

This is a story of why you should always check all the details of your particular insurance plan, even if you think you know them all. For your doctor may not tell you if you are overpaying, even if they’re making a profit from it. Or maybe especially if they’re making a profit from it…

My insurance card says on it “$20 co-pay office visits”. That’s all, in regards to office visits. Nothing more, nothing less. When we first got this insurance plan, I did read through the contract and terms, but I was childless and I think I kind of glossed over things relating to kids. When we had our first child, I started taking him to a pediatrician, and we paid $20 copays for all his visits, well-child and sick visits. I never thought twice about it, and the receptionist at the office happily took our money every time. I never let any kind of balance accrue, so I never got a bill of any kind, so I never really knew what the insurance company paid. The doctor’s office was happy, so I assumed they were paying the rest (which they were, but there’s more).

We became increasingly dissatisfied with our pediatrician’s office for other unrelated reasons over the course of the next two years, and soon after my daughter was born, we decided to look for a new pediatrician in the area we were moving to (which was only ~20 minutes away from the current pediatrician but since we were unhappy, we decided to make a change at that time). Concurrent with that, our insurance company started sending out explanation of benefits sheets for office visits in addition to the ones they sent out for everything else, and I noticed that my office visits ones, for a well child visit they said my portion was $0, whereas the sick child visits they said my portion was $20. I assumed that for some reason the copay wasn’t shown on the well-child visits and didn’t think much more about it.

We switched to the new office, and had our first well child visit, which I paid a $20 copay for. However, the next time I came in for a well-child visit, an interesting thing happened. The office told me that my insurance had responded to their billing letting them know that they do not charge a copay for well-child visits. So I got a $20 refund from the office for my last visit. I honestly was astounded. Was this a new thing? I called my insurance company, and no, all along I had no co-pay for well-child office visits. And in almost three years of well-child visits with my son at the other pediatrician’s office, no one had ever told me that they were being paid by the insurance company for my copay as well as by me. If you don’t have kids, let me tell you, you have a lot of well-child visits in the first two years. Nine or ten of them, actually. After that they taper off to once a year, but I had had ten well-child visits with my son and four with my daughter before we switched to the new office. $280 of copays we shouldn’t have paid.

I called the old pediatrician and basically, they claimed ignorance. They did say once I hounded them enough that they could see for my most recent visits with my daughter, they were compensated for my copay, so they did eventually refund $60 of my payments. But they claimed they had no record of anything before that in regards to my copays and what the insurance paid, and they could not go back any further (basically they refunded the ones paid in the same calendar year as I was calling in). Honestly, one of our issues with that office that made us switch was their utter lack of organization, so I can believe they have no clue. And I am certain they would have never told me that their records showed they owed me even $60. Ever.

My insurance plan is a pretty popular one in my area, so I wonder how many more people are paying doctors copays that they have no need of paying? Make sure you check all the details of your insurance plan – you are your best (and only, sometimes) advocate.

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24 Responses to “A Tale of Two Doctors”

  1. Wow!

    You are so right about this. We’ve done plenty of doctor changing due to incompetent office staff. Why do these doctors not care more????

    Can your insurer provide Explanations of Benefits further back? If so, armed with them and your own co-payment receipts you should be able to recover the rest of your overpayments, even if you need to go to small claims court. Unless the statute of limitations has expired…

    Even $60 of reclaimed money is good, though. Yay!

  2. That’s terrible how the doctor’s office took your money & the insurance company’s too! You should file a complaint with your insurance company about what they are doing. Also you should request a copy of your doctor’s visits to find out what the insurance company paid & compare it to your records & see if they owe you more money. If they do, go back to them with your findings but make sure to put it in writing. It might not hurt to c.c. your insurance company on the letter too, just think of how many other people are doing the same thing with this quack!

  3. Glad you found this out and were able to recover part of the money! I just want to tell you that from a different angle, I got a bill from a doctor that I had seen years (5+) ago recently. I just ignored it. The only thing that I could think might have happened is that they did not submit it to my insurance at the time. Now that I have no access to that old insurance, I don’t want to be liable for their poor organization. You do have to stay on top of things, going both ways : )

  4. crazypumpkin Says:

    April 3rd, 2008 at 5:02 pm

    I’d report that old doctors office to your insurance company for insurance fraud. Let your insurer know that you paid the office copays when they weren’t due when and are unwilling to refund you that difference. Even if you get nothing out of it, it lets your insurer know that the office may be participating in fraud.

  5. That’s so scummy of them! And that’s also part of the reason that health insurance is so costly–the consumer isn’t actively involved in the billing process the way she should be.

  6. I agree with crazypumpkin about letting your insurance company know about possible fraud. I also agree with Kacie’s whole comment :)

    I’m glad you’re at a better office now. It must make you feel good to be working with people who are honest!

  7. You should definately alert your insurance company. They can investigate, and ask the doctors office to provide backup. When the doctors office cannot substantiate because of their poor record keeping, they will be terminated from the insurance companies preferred program. You will save others hundreds of dollars by doing this.

  8. It never occurred to me to alert my insurance company as to insurance fraud. That is a good idea.

    Why I didn’t notice in the first place is that our insurance company didn’t send out explanation of benefits for office visits until fairly recently, just for lab tests etc.

  9. Hello…from working in the legal field for 20+ years, THIS IS AN ILLEGAL PRACTICE! (I’m willing to bet they smiled quite brightly at you every time you handed them the $20 check) Ignorance is no excuse…contact your insurance company immediately. They will have the records and be able to investigate this office. You would be doing a public service by saving others from making the same mistake and helping to keep insurance premiums down. As an alternative, go back through your checking account and look for cancelled checks. Confront them and, at the very least, get your money back!

  10. Wow that is certainly an eye opener. I recently had to have surgery and I had to fight with them to get the detailed bills.

    I compared every single payment with the bills they sent the insurance and made them explain everything to me.

    In your case, think of the number of people who bring their children in and how many times they too pay the $20. That adds up to a LOT of money over the years.

  11. I agree with the other comments – call your insurance agency and let them know.

    I had an interesting (not nearly as bad) experience with my doctor. I went for a specialty visit, and my copays are $30 for a specialist, so I paid it. Then months later I got a bill from the doctor saying I owed $25 for an office visit. I called back, mentioning that I paid the co-pay, left a message with them, and never heard anything again. I didn’t owe them anything, and I think it’s obvious from the fact that they didn’t return my calls (3 weeks so far).

    You always have to be careful and make sure you understand your insurance policies.

  12. This would make my dad so mad. There have been plenty of times that he’s waived the co-pay because the patient couldn’t afford to pay. To think this office was taking the additional money from you (intentionally or otherwise) is very frustrating.

  13. I’m based over in the UK and we are in the fortunate position of having free medical provision, which means that we have to worry less about medical emergencies. I’m not sure how much longer this practice will continue and I’m sure that in the coming years it will start to be privitised, but it really makes a difference. However other things in the UK are much more expensive like mortgages and house prices which off sets this. Sorry to hear you’ve been having problems

  14. Yikes. We’ve got a similar-but-not-really situation going on with our dentist’s office. I think we should take care of it before too much time pasts and they “forget” and feign ignorance and it becomes much harder to get our money back.

  15. That’s insurance fraud. Call your insurance company and also your state attorney general and/or your state insurance regulatory agency. Some insurance companies fall under a different federal agency, but start with your atty general. It feels like a pointless drop in the bucket, but let me tell you a story. A couple years ago, my mother was very ill and needed nursing home care. When she was transferred from the hospital, an expensive, nonformulary medication that she had brought in from home was “disappeared” by the nursing home pharmacy. Turns out it was sent “back” to a mail order pharmacy when she was briefly hospitalized. The same thing happened twice, and each missing prescription was about $3000. It didn’t cost us a dime out of pocket, because the missing medicin was replaced, and when I called the insurance company, their response was lukewarm. However, not six months later, there was a big news story about how that same mail order pharmacy was busted for insurance fraud. I am pretty sure they were taking back returned meds and reselling them. Probably also overbilling medicaid and other stuff. My mother’s missing meds were an accident, because that pharmacy would never have dispensed that particular medication. But because of this, we were able to blow the whistle. I’ll never know if our report made any difference, but I like to think we struck a blow for the little guy that day. Your $220 may not seem like much, but if they have taken a similar amount from just $1000 patients…well, that’s one very nice boat that somebody has bought. And it’s also a serious crime.

  16. Absolutely you need to inform the insurance company.

    Dollars to donuts this is not an “innocent” or “incompetent” mistake. I’ve had similar incidents: where a doctor’s office billed me for services the insurance company had paid for.

    If your insurance is through your employer, you might want to inform your HR department, too.

  17. I suspect that you could work through the insurance company to get the records you need to prove that everything was properly paid. I think you should try to call the office again, tell them how much you think you are owed, and tell them that you will be consulting a lawyer about your options to collect if they are unwilling to pay. Sure, unless you know a lawyer, it is a bluff, but I bet they will fall for it.

  18. That’s so frustrating! I learned from reviewing the Explanation of Benefits (EOB) that the insurance company sends after each doctor’s visit that our plan also covers preventive care visits 100% and there is no copay. The first time it happened, I had my husband send a letter demanding a refund of the $20 copay to his doctor’s office – since he only goes once every couple of years, I had a feeling it would disappear if we didn’t act quickly. It would have been a different thing if it was our pediatrician’s office – I have paid more $20 copays than I can count now, what with all the colds my kids have had in the last two years, so with them, I would have been content with a credit on our account.

    I do think doctors underestimate how much patients hate when their staff is disorganized. I changed primary doctors a few years ago, because even though I loved my doctor, I couldn’t stand his staff. Have you considered sending a letter to the former pediatrician? I suppose his staff might intercept it, but you could also call and ask to have the doctor call you back. I’d bet the doctor either has no idea that this is going on, or at least that this sort of thing could cause patients to leave. Although I suppose if your complaints were about the doctor, too, you might not want to do this.

  19. Thanks for all the feedback – I am following up with my insurance company and we’ll see what happens. I don’t have “records” of every copay we paid, because the earliest ones with my son, we had reached our FSA limit so I didn’t keep the receipts for taxes like I do for FSA stuff. I could get the debit card payment record from my bank if I needed to though. But we’ll see what happens.


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