Insurance ethics question

[sugarsue]

So my insurance company says it does not pay for Dr. B's visits because they are phone visits. They are $350 or so each appt. I just got a check in the mail for the entire visit. Do I keep my mouth shut and just be happy with this or do I call to find out if they should have been paying me all along with the risk that I'll have to send it back. If I keep it, is it fraud? WWYD?

Thanks!

Susan

[pepperlc]

hum. that is a tough one. i would call because you don't want them to come after you later. and you might find that they will now cover the others. I don't think its fraud on your part but you don't want them after you either.

they are so evil.

we still can't get them to cover reuben's medically necessary allergy meds. now they have told us that its because of dh's company that they don't cover it after 3 months of giving us tons of other excuses.

k

[Tonya77]

My MIL went thru this last year with her prescriptions. They had covered them all along and then they stopped. So she called to see why (not knowing that they werent suppose to be covered). She then owed over $300 AND they sent her to their fraud department. It was bad news but she was able to show them that she hadnt been fraudulant. Geez, if she knew it was wrong she wouldnt have called to see why they stopped it. So, if I were, I'd call. Better to be safe than sorry... even if insurances dont have any ethics themselves.

[sugarsue]

Thanks you two

I think I need to call. Maybe I'll get lucky and find out that they owe me a bunch of money. I kind of doubt it but at least then I won't be wondering and nervous of getting caught!

Susan

[pepperlc]

absolutely. even when its their mistake they won't be very nice if you owe them money.
k

[angeleena]

hard question!

let us know what happens!

[sugarsue]

OK, here's what happened yesterday

It turns out the dr's office coded the claim as a regular office visit so as far as the insurance company is concerned at this point, it is paid OK. I'd have to go back to the dr's office, get them to correct it and get it re-submitted. I decided not to do all that and let it stand. I'll be prepared to pay it back if needed but it would be a lot of work to get the insurance company to understand what happened at this point. It was difficult explaining what I did to the lady I spoke to. Since the codes were clearly different and it's more of a dr billing issue now instead of an insurance company/member problem as I see it. What do you think?

Plus, I won't be seeing Dr. B as often now (maybe 1-2 times a year for a consult if needed) so those bills won't be coming in like they currently are.

Susan

[trek]

wow. leave it.