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I Need Help Understanding Why This Isn’t Insurance Fraud? if Not- Why Aren’t There Any Safeguards for Insured?
True Scenario:
Go to Physician
He is employed by the hospital you work for.
Your insurance is through that hospital, your employer.
The physician has signed a contract with and is a preferred provider for your insurance- as your PCP.
You have a health condition that requires you to receive the pneumonia vaccination every 5 years.
You go to Dr.s office and they tell you the vaccine is not covered by your insurance. The cost will be $120.
You decide to go home and verify (5yrs ago it was covered same doc/same insurance)
The insurance company says it is covered.
You call the physicians office. You get the Tech. They say that “it is covered but they don’t pay me enough to do the shot. So we don’t use the insurance on that. You must pay the $120.”
Now another patient, with medicare, gets same shot- his insurance is filed. He pays nothing.
They (office manager) say they have the right to do that on items that would not make a profit.
Um- I thought thats why we had insurance?
OK ask the insurance to nominate another doctor because he will not play the game. The argument is actually between the insurance Co and the doctor so it is up to them to provide a doctor who will provide the service you have paid for
I would contact the State Insurance Commissioner. They usually have someone to assist consumers. Also I would contact the insurance company, usually the providers on their list have a contract agreeing to provide services for the contract rate. I am not aware of any contract that allow them to pick and choose which services they will provide at the contract rate.
I hope you voted for Hillary Clinton. She’s really rabid about health insurance issues. I don’t really like her socialist views, but I voted for her anyways.
You’re right. It is fraud. Unless they notified you of specific changes to your policy, the shot should be covered. Cal a medical malpractice lawyer.
It is only fraud if they bill the company for the shot after charging. Can you go to another doctor? Have you contacted the insurance provider. If he is paid and has been refusing covered benefits, then there might be fraud. You will not be the victim, but it should help you get the medical care you need.
Just because you’re with the same employer and with the same insurance, it doesn’t mean that the coverages didn’t change. Your employer can reduce/add any type of medical coverages on your plan at anytime.
Medicare usually pays all bills that the patient has. Medical insurances are contracted between the provider and the insurance company. In order for your employer to reduce monthly premium costs, insurance companies receives discounts from the providers. The providers do have the choice to provide service or not. If they’re cost is greater than the amount of money they receive, it’s not worth it for them to provide the service.
The reason that it isn’t insurance fraud is because it’s a private organization (hospital) which has its own private insurer (insurance company).
The doctor and you are both employees of the hospital, and the hospital owns the insurance company. Whether they claim to or not, they do (or it could be that the insurance company owns the hospital, but they are definitely in bed together).
If it were any other scenario, it would definitely be insurance fraud or at the very least, breach of contract. But because of their relationship, technically all parties are the same company, it is inside operational maneuvering.
What I would do, is ask the insurance company what they consider “reasonable and customary” charges for that shot and the visit to get it. Take that figure to your insurance rep at the hospital and tell them that the insurance company will pay this amount and you will pay the difference. (This is normal with most insurance plans.)
If they still refuse to do it, then contact the insurance commisioner in your state and explain what you have on here and what you did with the offer of payment over the r&c charges. Their office should be able to help from there. They will definitely do an investigation into it.