Advice on how to handle possible billing fraud

[cwalner]

I just received a bill that I think may be fraudulent and wanted some advice on how to proceed.

To clarify, the bill I received was for an ambulance ride that I did in fact receive, but has already been paid by my insurance. There are several reasons why I think the bill is intentional fraud and not simply an error.

The bill was postmarked 09/02/09
According to my insurance (Aetna) website the bill was paid on 08/25/09
According to my insurance website the bill is closed with my responsibility as $0 indicated.
The bill includes a sticker, the color of yellow highlight, soliticing credit card payment
The bill contains the comment "Your insurance has been billed. Please forward any insurance payments to us".
According to the insurance website a few of the minor charges were specifically declined as having already been provided by another company. (this was for transport from the Emergency room of one hospital to another hospital to be admitted - they charged my for an IV start when the IV was put in by a different ambulance that took me from my home to the emergency room)


It was too late to call the company as to discuss this as thier offices had already closed and I know I am too angry to be rational about this because there were other issues that had me upset about the bill that were probably not fraud, but questionable in the amounts billed.

As mentioned above this was for transport from one hospital to another. No actual emergency care was provided during transport. Still they billed a total of $695.00. The ambulance that actually came to my house, gave me oxygen for my breathing distress, gave me medicine for my heart, and did in fact put in the IV, billed a total of $407.00

The entire ambulance ride was unnecesary, but became required because of something the first ambulance did. I knew that I was suffering from Pneumonia as this was not the first time for me. I requested to be taken to Community Hospital North. However, when the first ambulance questioned me about my medical history, I told them about my existing Heart condition that I am receiving ongoing treatment for. They chose to err on the side of caution and take me instead to The Indiana Heart Hospital, a hospital in the same complex and part of the same network that specializes in Cardiac care. However once the emergency passed and the doctors confirmed my self-diagnosis, which was not a heart issue, they could not admit me to the Heart Hospital and had to transport me to Community Hospital North for continuing treatment. (also note that the two hospitals are close enough to share a parking structure and a tube system for transporting documents, but have no connecting passages for transporting actual patients - yes my insurance was billed aprox $700 to transport me less then 500 yards/meters)

As you can see, while I do think some of the bill may be fraudulent, I am also clearly already upset that I received a bill at all and request you, my fellow forumites who can remain objective, to offer some advice on how to proceed.

Please note, that since my insurance has already closed this, under no circumstances will I pay any money. I am questioning how aggressive I should be with them when I do get a chance to contact them and whether I should file complaints with any consumer agencies and/or file a criminal complaint.

[UNLoVedRebel]

Wish I could help but I can't:mad:

[quixotecoyote]

If you can afford a lawyer, now'd be a good time.

[cwalner]

If you can afford a lawyer, now'd be a good time.

Since you are asking if I can afford a lawyer you seem to think that they will take legal action against me, rather then suggesting I take legal action against them (as that would be on contingency and my ability to afford would not be an issue).

My I ask why you think that?

[fezzic]

Assumption: You're being billed for the $695 that your insurance company says it paid. In that case:

Given the day payment was made 8/25 and the postmark on the bill which was 9/2, I ask that you examine the bill and see when the billing date was which will not be the postmarked date. Chances seem good that the billing date was at least several days earlier than the postmark and at the time the bill was generated the payment had not been received or entered into the accounting system. A case of the incoming payment and the outgoing bill sailing right past each other.

You might call and inquire about the bill, after all by all you know the ambulance company was paid, and see if their records still show that $695 balance. If it doesn't (i.e. zero balance) you can forget about the bill (if you are paranoid you can note when you called, who you talked to, and what the outcome was).

If it does still show a balance, you can inform them that your insurance company has told you that they paid it on 8/25 (probably by check). It is possible that the check got lost in the mail, was delayed for some reason but finally will get there, or is stuck in their system. At the least, they would be on notice that payment had been sent -- if they want they can check with the insurance provider for confirmation.

I suppose this could get ugly (lawyers and all) but a calm attempt to get at the facts might be enough to make this go away.

That's the best I can think of right now.

[rjh01]

How about discussing it with your insurance company? Then the company that sent you the bill? Or maybe the other way round?

Remember the world will not end if you do not pay the bill for a few days after receiving it.

[boooeee]

What rjh01 said. Call the company and then call the insurance company. Getting a lawyer involved is WAY premature.

I had a similar situation with a doctor's visit. They had me pay for the full cost at point of service because their records indicated I hadn't met my deductible. It turns out I had, and the insurance company sent them a check for the cost. When I found out about it, I called the doctor's office, and they refunded my money.

[jhunter1163]

Ah, a case where I can be of service. I was an insurance biller for one medical practice or another for 15 years. Here's what you should do;

#1. You're absolutely correct to pay nobody anything.

#2. I'm assuming here that the bill you are questioning is from ambulance company #2 (the one who didn't actually do much of anything). Unless you have very good insurance indeed, it's rare for patient responsibility to be zero for emergency transport (usually there's some sort of coinsurance/copay). Check your explanation of benefits again and see if the claim was denied for some reason. I suspect that your health insurance policy has a clause which says that only one ambulance trip will be covered per hospital admission. If it was denied, and I cannot emphasize this enough, you are not responsible for the bill. Ambulance company #2 will have to take it up with Aetna.

3. Enlist the help of your insurance company if you have any problems with company #2. Your insurer is on your side; after all, you (or somebody) pay them premiums.

4. Charging $695 to transport someone from one side of a building to another is excessive in my opinion, for whatever that's worth.

If you have any questions or need any help, you can PM me.

[cwalner]

Thanks for the advice.

A few points of clarification that were brought up.


I checked the invoice and it is dated 09/01/09
I know it is for the second trip because of the company name and the invoice details the pickup and dropoff locations
Aetna did not pay the full $695. Per thier website they pay a reduced negotiated rate ($476.25), but still clearly indicate my responsibility on the bill is $0
The reason my portion is $0 is not that they typically cover full expenses for ambulance, but that I have already paid my max contribution for this year ($2000.00) so instead of my being responsible for 20%, I am not responsible for any charges until the next calendar year.


Also even when I posted originally, I had little doubt that once I call the ambulance company, and discuss this, my bill will be taken care of. The reason I am angry and wish to report this, is that I can easily imagine a lot of people not thinking of checking with thier insurance billing first (having access to good site like Aetna maintains makes this very easy and I think such sites are rare) and paying the bill even though it was already paid by insurance. Then they would have a much bigger struggle to get the money back if they ever do realize they should not have paid. To me this type of deceptive billing is unethical at the least, fraud at the worst.

Jhunter as you seem to be inside the industry I have another question specifically for you (or anybody else who also knows how such things work).

I also received a bill from the ambulance company that took me to the ER in the first place. They did not however bill me for the full amount, only for the difference between what the original charges were and what Aetna paid as the negotiated price.

per the website:
Charges Submitted $407.00
Charges at Aetna's Agreed Pricing (thier wording not mine) $277.70
Paid by plan: $277.70
Not paid/excluded by plan: $0
Applied to your deductible: $0
your Copay: $0
Your responsibility: $0

I received a bill from the ambulance company showing the following:
Charges for emergency transportation: $407.00
Insurance payments: $277.70
Patient balance: $129.30.

Any suggestions on how to approach that ambulance company about that $129.30, which according to Aetna is not my responsibility?

Please note that earlier in the year, I received many medical bills that showed the same reduced rates, which Aetna then only paid 80% of per my plan and on those I only received bills from the HCP for the 20% balance after the discounts were applied.

Again, thanks in advance for any advice you have to offer.

[jadebox]

Also even when I posted originally, I had little doubt that once I call the ambulance company, and discuss this, my bill will be taken care of. The reason I am angry and wish to report this, is that I can easily imagine a lot of people not thinking of checking with thier insurance billing first (having access to good site like Aetna maintains makes this very easy and I think such sites are rare) and paying the bill even though it was already paid by insurance.

...

They did not however bill me for the full amount, only for the difference between what the original charges were and what Aetna paid as the negotiated price.

We've had many cases where a doctor or hospital has billed us for the difference between the amount they billed the insurance company and the amount the insurance paid even though we are in a plan where the provider agrees to accept the negotiated rates. When you call the doctor or hospital about it, they quickly admit that sending the bill was a mistake. But, since it happens often, you have to wonder if they are just fishing for money they are not really owed.

-- Roger

[fuelair]

We've had many cases where a doctor or hospital has billed us for the difference between the amount they billed the insurance company and the amount the insurance paid even though we are in a plan where the provider agrees to accept the negotiated rates. When you call the doctor or hospital about it, they quickly admit that sending the bill was a mistake. But, since it happens often, you have to wonder if they are just fishing for money they are not really owed.

-- Roger
Actually, no, you do not need to wonder about that! They are.:)

[jhunter1163]

As you pointed out, the ambulance company agreed to accept Aetna's rate for the transport. This isn't a gentleman's agreement; it's a contract, and they are legally bound to accept it. You should call them and gently point this out to them, and they should do nothing other than write it off.

And, as other posters have pointed out, if even a few patients just unquestioningly pay that difference, the provider is money ahead. It's dishonest to say the least and fraudulent to say the most to bill for that difference.

[cwalner]

Well, I finally got a chance to call the ambulance companies

The good news (for me) is that both ambulance companies acknowledged that I did not owe anything further and that the accounts are paid in full. In fact both stated that up front as soon as I said I was questioning the bill and confirmed that the action taken to clear the accounts was done before the call.

The one that triggered the issue (the $695.00) stated they received the payment from Aetna on 09/01/09 (the same date the invoice was printed) so it was a matter of the payment arriving just a hair too late to be reflected on the invoice. I am not quite sure I completely buy this as Aetna shows the check issued on 08/25/09. I find a week delay in posting a payment a bit of stretch in this day of EFT payment processing. However, I could not argue much with them as what I wanted was taken care of.

It turns out the other one was a bit more problematic. Their invoice acknowledged the payment received on 08/28/09 (Aetna claims to have paid it on 08/18/09). The issue with them was that they sent me the invoice on 08/31/09, but did not post 'the credit for the insurance discount' until 09/04/09.

So, I have a case where the evidence suggests to me cases of 'send the bills to both the patient and the insurance and see if both pay' but is a far way away from proof of such because I did the right thing and questioned the bills before paying them. It just still boils my blood to think of how many people actually pay and then realize too late, or never realize at all that they overpaid.

These types of billing practices seem so dishonest to me, but I am not sure that I have any standing to file a complaint, since I questioned before I paid and therefore was not financially damaged as a result.

[NoZed Avenger]

These types of billing practices seem so dishonest to me, but I am not sure that I have any standing to file a complaint, since I questioned before I paid and therefore was not financially damaged as a result.

You might follow up with your state's department of insurance (or equivalent). They may investigate or at least make note of the complaint so that if more complaints come in and a pattern develops, they can then get into gear.

[not legal advice in any way, shape, form, shade, phase, method, or manner]

[cwalner]

You might follow up with your state's department of insurance (or equivalent). They may investigate or at least make note of the complaint so that if more complaints come in and a pattern develops, they can then get into gear.

[not legal advice in any way, shape, form, shade, phase, method, or manner]

I was thinking more along the lines of Department of Consumer Affairs (that's what it was in CA, not sure what they call it here in IN). I am not in any way, shape, or form upset with my insurance company. They are doing right by me.

I must say that prior to this year, I had bought into the meme of the evil insurance companies ruining health care. In my case, when I needed them, they were there for me. This particular incident, though, has me really questioning the meme as here, it seems as if the HCP are the ones inflating prices, and my insurer is the one working out discounts and keeping things cost-effective.

[oggiesnr]

This particular incident, though, has me really questioning the meme as here, it seems as if the HCP are the ones inflating prices, and my insurer is the one working out discounts and keeping things cost-effective.

The flipside being if you were not insured you would have to pay the full bill. I wonder if the HCP adds a percentage on because they know the insurer will bring it down but anyone without insurance (or visitors with overseas insurance) will pay the inflated amount.

Steve

[chrisjeans]

So, I have a case where the evidence suggests to me cases of 'send the bills to both the patient and the insurance and see if both pay' but is a far way away from proof of such because I did the right thing and questioned the bills before paying them. It just still boils my blood to think of how many people actually pay and then realize too late, or never realize at all that they overpaid.

I think that's exactly the way they operate. After I received some very expensive care, I was billed roughly every 2-3 weeks for emergency transportation (by helicopter) while they were also negotiating with my insurance company. There was no reason to be sending me those bills, except to scare me.

Those bills kept coming long after my insurance provider had paid them.

In the end I had to get some very high-up help from my (very very helpful) HR/Benefits staff at my workplace to make them stop.

Question every bill you receive.

[jhunter1163]

I was thinking more along the lines of Department of Consumer Affairs (that's what it was in CA, not sure what they call it here in IN). I am not in any way, shape, or form upset with my insurance company. They are doing right by me.

I must say that prior to this year, I had bought into the meme of the evil insurance companies ruining health care. In my case, when I needed them, they were there for me. This particular incident, though, has me really questioning the meme as here, it seems as if the HCP are the ones inflating prices, and my insurer is the one working out discounts and keeping things cost-effective.

Well, as with most things, it's not as simple as it appears. The fact is that healthcare providers pretty much have to take what the insurers give them. It's simply not practical for a provider not to participate in the insurance networks anymore. So, you could bill $10,000 for an ambulance ride, and you'll still get the same $277.50 and have no recourse against the patient for the balance. In the practice I work for now, our collections are about half of our gross billings (insurance adjustments and patient discounts/writeoffs account for the remainder.)

The real inflation in healthcare costs is in drug prices, and those are set by the manufacturers. The providers, again, are reimbursed what the insurance carriers agree to pay, typically the average sales price plus a small markup (6 to 10 percent).

Aetna, in my opinion, is one of the more policyholder-oriented carriers. Of course, everyone's individual experiences may vary, but based on 500 or so patients I'd say that Aetna is pretty good.

[jhunter1163]

Question every bill you receive.

My advice is never, ever to pay the first bill you get from a provider. Let the insurance do their thing and then review the bill to make sure everything is kosher. And definitely question anything you don't understand, especially if the provider is telling you that you have some responsibility.

[cwalner]

My advice is never, ever to pay the first bill you get from a provider. Let the insurance do their thing and then review the bill to make sure everything is kosher. And definitely question anything you don't understand, especially if the provider is telling you that you have some responsibility.

The thing that really got to me is that I received a bill, not a statement. Prior to this, I had received statements for the ER for about $6k and for the hospital stay for about $14k. Both were clearly stamped that they were statements, not bills and marked "DO NOT PAY". This lets them notify me of the total charges without causing confusion that that is the amount that I owe them.

And in my ongoing saga, I recieved a third bill today (actually a past due notice) from the Castleton Volunteer Fire Department. The only information I have is a balance of $462.00 and a service date of 07-25-09 (the date the ambulance took me to the hospital). Interesting, since this is the first piece of mail, I have received from them. I am assuming that this is related to the EMT treatment and the ambulance ride, but not sure why it was billed seperately and why Aetna had no record of a claim being submitted by them.

I called and got voicemail (they close at 4:30pm) so left a message telling them politely where they can file that bill until they can provide an explanation of the charges and proof that this has been submitted to insurance. (I was quite conscious, just having difficulty breathing so provided them with my insurance card at the time of treatment). I also figure as a last resort I can borrow a play form the Freeman on the Land, since they misspelled my name and appear to have assisted some fella named CWallar, not me ;)

[jhunter1163]

I called and got voicemail (they close at 4:30pm) so left a message telling them politely where they can file that bill until they can provide an explanation of the charges and proof that this has been submitted to insurance. (I was quite conscious, just having difficulty breathing so provided them with my insurance card at the time of treatment). I also figure as a last resort I can borrow a play form the Freeman on the Land, since they misspelled my name and appear to have assisted some fella named CWallar, not me ;)

Correctly handled. I'd be interested to hear their reply. It's unusual for EMT services to be billed separately from the ambulance ride, but not totally unheard of. Maybe they don't have an ambulance of their own and contract with the ambulance company to provide transport services. In any case, since your stoploss is met for the year you won't be out of pocket for this. They best hustle up and file their claim though; I think most Aetna policies have a 60-day timely filing limit. If they don't file the claim by then, they have to eat it.