Can I Sue Doctor for Lying to Insurance Company

[CamKay]

New Jersey

I put a claim in through my insurance company and my doctor was ordered --by them-- to pay me the balance of a certain procedure she had performed. Although she wasnt happy about it she agreed to pay. After 1 month and still no check i call her office to ask where my money is....get the run around...call insurance company who sends claim to provider relations since doctor still hasnt paid after about 2 months....Doctor is now stating that her office never gave me diagnosis and CPT codes that were submitted with claim---therefore she is not required to pay me anything(which is a lie i have the date and time and person i spoke to who gave me the codes) Can I sue HER for insurance fraud?

 

[lealea1005]

New Jersey

I put a claim in through my insurance company and my doctor was ordered --by them-- to pay me the balance of a certain procedure she had performed. Although she wasnt happy about it she agreed to pay. After 1 month and still no check i call her office to ask where my money is....get the run around...call insurance company who sends claim to provider relations since doctor still hasnt paid after about 2 months....Doctor is now stating that her office never gave me diagnosis and CPT codes that were submitted with claim---therefore she is not required to pay me anything(which is a lie i have the date and time and person i spoke to who gave me the codes) Can I sue HER for insurance fraud?

Is the Physician contracted with your insurance company? If not, she cannot be "ordered" to do anything by your insurance company.

 

[cbg]

"Ordered" to pay you the balance of a bill? Are you talking about a refund on an amount that you personally paid? Were you balance billed over and above the amount that the doctor was contracted to accept?

If so, your recourse is through the provider relations division of your insurance company, not the courts.

If not, your insurance carrier has no authority to "order" your doctor to pay you anything.

 

[CamKay]

Yes the doctor is in network....I paid upfront for the procedure and was paid the doctors contracted rate by the insurance company....however there is a balance bill of $515.50 that she is refusing to pay me....

 

[CamKay]

It went through provider relations dept and the doctor is now lying to them and saying her office never gave me the cpt codes.....isn't that insurance fraud on her end? I have the date time and person I spoke to who gave me the codes at her office

 

[ecmst12]

How is whether she told you the codes even REMOTELY relevent to ANYTHING?

You never should have been asked to pay up front for this; the provider is contracted, that means she's obligated to bill your insurance before collecting anything other than a copay from you.

 

[cbg]

No. You cannot sue the doctor for lying to the insurance company and No, this is not insurance fraud.

You do have recourse, but as I've already told you, that recourse is through the insurance carrier. You have a contract with the insurance carrier. The doctor has a contract with the insurance carrier. You do not have a contract with the doctor. Therefore, it is up to the insurance carrier to enforce the contract. You can't sue the doctor because your contract is not with the doctor.

 

[lealea1005]

I'm confused. If the Physician was in network/contracted, why wasn't the claim filed from the office...OR...if their contract doesn't require them to file the claim (which would be VERY unusual), why weren't you given a receipt with all the diagnosis/CPT codes that you could file?
Why were you required to pay at the time of service? Did you have a deductible to meet? AND...why were you required to pay the Physician's full fee?

You cannot sue the Physician for lying to the insurance company. As cbg alredy stated, the contract is between the Physician and insurance company. If the insurance company finds the Physician isn't abiding by provisons of the contract, they will terminate the Physician from their panel.

 

[CamKay]

Ok here is the fully story...

I went to an in network doctor for two procedures on the same day...the doctors office had the first procedure pre certified and the second procedure she said i would have to pay for upfront and would have to put in a claim through my insurance company myself because some insurance companies consider that specific procedure cosmetic....i checked with my insurance company and the procedure within my plan is 100% covered as long as medically necessary. I pay $1,200.00 upfront and get a reciept. I begin to fill out the claim form and need to call the doctors office to get a diagnosis code and procedure code for the procedure to submit the claim to my insurance company. After 5 phone calls i get the codes from a receptionist at the doctors office. I submit the claim. A month later it gets denied due to no pre certification. The insurance company calls the doctors office and says hey you are a contracted doctor with us and you knew you needed pre certification for this procedure why didnt you get it...The doctors office then states that in my case the procedure was NOT medical and was cosmetic therefore she is not required to get precertification...SHE NEVER TOLD ME IN MY CASE ANYTHING WAS BEING DONE FOR COSMETIC REASONS NOR DID I GO TO HER FOR ANYTHING COSMETIC.....The insurance company tells me to get all of my medical records, CPT and diagnosis codes, dopplers, sonograms and send it to them so a panel at the insurance company can review my claim to determine if it was medical or cosmetic....i do this....a month later the insurance company determines it WAS MEDICAL AND NOT COSMETIC**************The insurance company mailed me a check for $684.50 which is the doctors contracted rate for the procedure along with an EOB and they tell me to call the doctors office to get the balance of $515.50...I call the doctors office to tell them they need to pay me the balance bill since the insurance company determined the procedure was MEDICAL NOT COSMETIC despite what the doctors opinion was....the doctors office gets pissed that they have to pay me but agree a check would be mailed to me......A month goes by and i get no check.....i call my insurance company to be like what the hell.....they send the claim over to provider relations department.....provider relations calls the doctors office to ask why i havent been paid....the doctors office now CLAIMS they never gave me the cpt and diagnosis codes and the doctors office is saying i got the codes off the internet...


the insurance company says that since the doctors office is now stating that they never gave me the codes they are not obligated to pay me any balance bill because those codes were used to prove medical necessity....

I got the codes from a receptionst at the doctors office and never used the internet to get the codes. The doctor is just pissed cause my insurance company determined my procedure was medical and not cosmetic and she is going to get paid $689 instead of $1,200.

how is this not fraud? she is lying to the insurance company so she doesnt lose out on $500 by saying i made up these codes when i have the date time and person i spoke to.....

 

[ecmst12]

Your recourse is still through your insurance company.

 

[CamKay]

Your recourse is still through your insurance company.

the insurance company stated that they need the proper cpt and procedure codes when filing a claim. Since the doctor is CLAIMING her office never gave me those codes to the insurance company, the insurance company says the claim does not need to be paid out because of this...they state that i have to get the proper codes from the doctors office....and since the doctors office is saying they never gave me those codes the claim gets closed.

basically it is a he said/she said....i said the docs office gave me the codes, the docs office is saying no they didnt.... and the insurance company is basically siding with the doctor by saying its ok for her not to pay me...

the insurance company advised me to file a claim through my state medical board....

 

[cbg]

No matter how many times you ask the question, the answer is still going to be that your recourse is through your insurance carrier.

But for the sake of argument, let's pretend that we told you yes, you could sue the doctor.

How do you plan to PROVE that the receptionist gave you the codes? As you say, it's a he-said/she said situation. What kind of evidence do you have that would make a court rule in your favor? If the receptionist, either because she's lying to protect her job or because she's honestly forgotten doing so, says she did not give them to you, what do you have that will prove her wrong?

 

[CamKay]

No matter how many times you ask the question, the answer is still going to be that your recourse is through your insurance carrier.

But for the sake of argument, let's pretend that we told you yes, you could sue the doctor.

How do you plan to PROVE that the receptionist gave you the codes? As you say, it's a he-said/she said situation. What kind of evidence do you have that would make a court rule in your favor? If the receptionist, either because she's lying to protect her job or because she's honestly forgotten doing so, says she did not give them to you, what do you have that will prove her wrong?

I can not "PROVE" anything.... I did not record the conversation where the receptionist gave me the codes. I only have my testimony under oath as well as my medical records and claim information from my insurance company. I have my medical records, sonogram reports, and Doppler reports which the insurance company board reviewed and determined the procedure was medical and not cosmetic.

 

[ecmst12]

So this he-said-she-said issue should not even be brought up. Your insurance company has all the information they need to fight this for you. Make sure they do.

 

[CamKay]

The insurance company stated they can no longer do anything involving this claim and advised me to file a complaint with the state medical board....they said they have done all that they can