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doctor's office fraudulent on pre approval for surgery

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nancy1678

Junior Member
California:
My husband needed prostate surgery and waited 3 long painful months until his deductible was met so he could afford to have the surgery needed using a green light laser. The surgeon's office told us repeatedly that we were pre-approved for the surgeon and the hospital who had the needed laser equipment. One month after the surgery, we received a bill for over $20,000 for the hospital's portion of the surgery from the hospital. We then found out the hospital is not a contracted provider and the doctor's office never got the pre-approval. We then met with that surgery scheduling dept who deals with the preapprovals and they told us this is typical and happens all the time and all they need to do is make a few phone calls to appeal and the hospital bill will be paid for by the insurance company. They even provided us with the documents showing we were not preapproved and that the insurance company would not pay the surgery prior to the surgery. Sadly, we did not become aware of this by the doctor's office until a month after the surgery. We did tape record the conversation so we could remember the details. Within one hour of leaving the doctor's office after discussing this "easy appeal process that they would do for us", that same doctor's office called us and told us there was nothing they could do to help us with the appeal and we were on our own. It took 2 months to compile information for the appeal showing the closest green laser was 113 miles away from our residence. We received a denial letter from the insurance saying that if we were going to have surgery "out of network", we needed a referral and they would have paid for the surgery. Since we were told we were preapproved, how would we have known to get this "out of network" approval and now we have been thrown under the bus with a $20,000 bill that we are being asked to pay. Is this criminal intent to commit fraud by the doctor's office? What recourse do we have? We were stunned at this outcome.
We know you can not use the taped conversation in a court of law, but can you use it in a mediation situation to prove our point that the doctor's office did not tell us the truth prior to the surgery? Isn't the doctor's office responsible for that bill since they lied to us?
 


ecmst12

Senior Member
Your husband had a responsibility to call his insurance and confirm whether the approvals were all in order before having the surgery, and if not what needed to be done to get it in order. He should not have just assumed everything was ok. There was no fraud here, this was simply him not taking responsibility for his own care. You can't blame the doctor for that.

It makes no sense that he would "wait to meet his deductible" before having surgery either. The amount of the deductible is the same regardless of whether it's paid for one service or several.
 

lealea1005

Senior Member
Agreed.

Approval for the procedure (surgeon) is separate from the approval for the hospital/facility. The Physician usually has no informtaion regarding the contract status of anyone but themselves.

You could try calling the hospital and ask them whether they would consider discounting the fee to the amount that your insurance company would have paid if it were considered in network. Don;t hold your breath, but it may be worth a try.

In the future, call your insurance company to confirm whether all Physicians & facilities you'll use are contracted and all approvals have been granted.
 

momm2500

Member
Depending on the insurance plan and the company, if a pre-certification has been completed.....the member receives a letter stating so. Confirm that with the insurance company.
 

nancy1678

Junior Member
doctor's preapproval process with hospital

When my husband asked the doctor's office if he was to get the pre-approval, the docotr's office said they will get the pre-approvals for surgeon and hospital. He called and spoke in person to the doctor's office about the pre-approval process twice to follow up and they told him all approvals were done and he was scheduled for surgery and all he had to do was call in the day before the surgery to reconfirm the surgery was still as scheduled.
He specifically asked if the hospital was a contracted facility and they told him it was.
 

lealea1005

Senior Member
Once again....your husband is the one ultimately responsible for confirming his policy specifics. HE should have called his insurance company to confirm whether the facility was in network.
 

Klawman409

Junior Member
Sue the doctors office and the facility for fraud

I disagree with those opining that it was your husband's responsibility to confirm coverage with his insurer. Arguably, he was negligent, but no reasonable jury is going to stick it to the patient if they believe that the doctor's office misled him. I don't have enough facts to say for sure, but it I suspect this was fraud on their part and not just a negligent mistake.

Unfortunately, more and more doctor's are getting greedy and their offices are being very cute about what the tell patients. For example, I just was on the phone with a Califonia office that told me that the doctor was in-network. What they didn't say, but I found out by making some inquireis, is that the reason they have been making excuses not to do an insurance predetermination is that they probably intend to bill for doing the test in an out of network facility. They specifically told me that the stress echo was done in the doctor's office.

They also told me that I only pay $20 at the time of the test, as if that was all that I had to pay. What they didn't say was that I later will be billed for a heck of a lot more.
 

ecmst12

Senior Member
There is no viable lawsuit without a legal duty. The legal duty to confirm insurance requirements rests on the PATIENT, not the doctor. No lawsuit. Period. Never rely on someone else to do your job for you.
 

justus2011

Junior Member
should'nt the doctors be responsible to at least inform the patient that they should contact the insurance company.We were told no pre-approval was necessary and had no idea about coverage till we got letter of denial from insurance company.
 

ecmst12

Senior Member
Don't hijack other people's threads. Start your own thread if you have a question.

However, if you READ this thread, your answers will not be any different.
 

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