A few weeks ago, my tooth started hurting, and little did I know I would end up with a great example for how fraudulent billing practices can be small and sneaky.
First, I went to my regular dentist, who is phenomenal. She is kind, caring, and I have never had a single issue with her billing. She thought either some old dental work was failing or I had a fracture on the root of my tooth. To check this out, she sent me to a specialist for a specific type of imaging that would check for a fracture. If there was no fracture, they could treat the tooth. If there was a fracture, I would lose the tooth.
This, of course, made me nervous up front. This specialist was out of network, which meant I had fewer protections from my insurance company. This is sometimes a red flag as providers who work in areas where patients have fewer options for treatments are doing so because they can charge what they want. However, he was the only provider in the area who had the specific type of imaging I needed, so my regular dentist sent over my records and off I went.
Red Flag #1
The first thing this practice did was give me a sheet of paper where on one side I wrote my medical history (ok, normal) and on the other side was a treatment plan I was supposed to sign where I agreed to pay over $900 up front. Since I had not seen the dentist yet, this was rather suspicious and a red flag for fraud. I did not sign it.
The dental assistant took me back to do the imaging I needed. Then we went into a treatment room. She asked me if I signed the treatment plan. I politely with no hint of confrontation told her I was going to wait to be sure I needed it before signing anything. She agreed that was completely fine and we thus avoided the issue.
Asking patients to sign treatment plans before being seen by a provider is fraud. Don’t do it.
Red Flag #2
It turned out I had neither a fracture nor needed a treatment, so I was happy I did not sign the dental plan. No $900.
Now here is a part where I became confused and you can see that even in the moment, anyone can be taken off-guard when someone does something that is irregular, whether it’s permissible or not. After being escorted to the front desk, the receptionist asked me for the money for the imaging. I said that my insurance should pay for that. She said they bill out-of-network and they’ve never seen insurance pay.
Now, they can do this, but it’s very rare for providers to ask for co-insurance before billing the insurance company. So it made me suspicious. Nevertheless, I paid the requested fee and decided to watch my EOB very carefully.
She printed off a receipt and I thanked her and walked off.
Later, I looked at this receipt. They had billed 3 codes. That’s odd, I thought. They should have billed for an examination and the image they did. Upon closer examination I noticed it:
They billed for the x-ray my general dentist had done.
This is fraud.
They billed me for services not performed. Maybe THIS is why the insurance company wasn’t paying for the specialty imaging: you probably couldn’t bill both images together. Now, he did look at the x-ray and if I had noticed the issue before walking out the door and said something, that’s probably what they would have argued. However, looking over images and tests that others have performed is part of the examination. Only if he performed the x-ray could he have billed for it. It’s totally fine for the person who performed the x-ray to bill for it, even if they do a separate examination. But you can’t bill for things other providers have done.
As a side note, what if your physician tells you that you need an x-ray and sends you to another radiology clinic separate from the doctor’s office? Then the radiology clinic should perform the service, bill for it, and send a report back to your doctor. The doctor should bill only for the examination.
From here I had two options: I could let it go (it’s $30 that was billed to my insurance, not to me) or I could have turned him into the fraud/waste/abuse department at the insurance company. I knew my insurance company probably would not care about a $30 charge, so I decided to wait to see what happened with my EOB. If my insurance didn’t pay the full amount, I would let the dental office know that I would not be paying the $30 as it had already been paid on another claim, the claim my regular dentist made. And then inform my insurance company. If I didn’t owe anything else, I decided I would let it go.
Sometimes Nice People Do Bad Things
The specialist himself was very professional and competent and while I felt uncomfortable with the billing process, I was pleased with the care he provided. This is why it’s important to keep a few things in mind:
Sometimes people just don’t know the rules. They’re trying to prevent a problem, such as patients being surprised by having t0 pay $900 up front. And they’re charging up front to prevent loss
Sometimes even if the people billing and coding know the rules, the provider doesn’t know that they’re doing something wrong. Sometimes the provider has no idea what the office is doing and does not realize that he or she can get in trouble for it.
But sometimes, even nice/professional guys commit fraud. Sometimes the provider is well-aware the billing is wrong or fraudulent and does it anyway.
Chances are, you won’t know which category your provider falls into if you have a problem. I always approach things as if people have the best intentions. People tend to respond better to collaboration than accusation. I also don’t know everything, so perhaps I am wrong! So always start off with curiosity and asking questions, move to assuming the best, and save accusations for if they’re truly necessary.
Takeaway:
Fraud is everywhere. Sometimes it’s on purpose and sometimes it’s not, but know your rights and never sign anything before seeing a dentist or a physician, and keep a close eye one what they’re charging you. If you are confused, you are not alone! Everyone gets confused. Even the people coding these things gets confused. But watch out because these little fraudulent charges add up. If you have any concerns, ask your provider. If you still feel uncomfortable, call your insurance company or ask a billing consultant.