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Doctor wrongfully collecting deductible and not refunding.

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Purrrl

Junior Member
What is the name of your state (only U.S. law)? California

I have a hot mess of a situation. My doctor's office wrongly collected a deductible for services covered under an office visit copayment. They collected $297.70 which was a $30 copay from a previous visit plus $267.70 which was what they said I owed for my deductible. When I realized my insurance covered everything but a $30 copayment and issued payment to my doctor's office I called the billing department asking when I would be issued a refund. I had to call several times and leave messages with no return call. Finally I got the billing girl on the phone who said she would try to expedite the situation and to call back in a week if I hadn't heard anything, so I said okay and that in the meantime I had received a statement from them for a $30 copay and if she could pay for that out of the refund. The following week I get a check for $107.70, which is $100 less than what it should have been. After numerous voicemails and finally going through the front office staff and demanding to speak with someone the biller gets on the phone and tells me that their system checks for no show fees before it issues refunds. I'm astounded.... I have zero no shows since becoming a patient there. I ask to speak to the office manager and am told that if I do that she will probably tack on more. At that point I realized I wasn't getting anywhere and being threatened and I politely ended the call.

Since then:

I have found out from my insurance that my benefits clearly state any procedures done while in an office setting and being charged in addition to an office visit charge do not apply to a deductible. Basically the only things that apply to my deductible are outpatient surgeries where an office visit is not charged, labs and diagnostics, hospital and er charges. Anything done in an office visit doesn't apply to the deductible and it clearly states that, so the doctors office should have known. The claims department told me to contact fraud and ethics department to see if there was anything they could do. Fraud and Ethics said that it violates their contract with the doctor if they knowingly collected money they knew I wouldn't owe in order to withhold it from me later. So a fraud case was opened through my health insurance. Still pending.

I tried to dispute $100 of the original charge through card services for my flex spending card I used to pay for my deductible. The reason I used for the dispute is that flex spending dollars were used to pay for no show fees instead of the deductible I was told I was being charged for. They denied the dispute because they can't issue a chargeback because I gave the provider my card and signed for it.... even though I didn't authorize it for no show fees....

I have since tried to get any documentation I can from them stating the funds were specifically applied to no show fees, and also documentation of when these supposed no show fees occurred so I could dispute them. I was told that only the office manager could print out a complete list of my appointments but she was unavailable, after I was already told it would be no problem and a copy would be waiting with my medical records when I came to pick them up. So I had the front office staff read off every appointment so I could write them all down and got the receptionist name and dated it so I have a record in case anything else comes up.

I received a new bill for $100 even though they still owe me $100. When I went in person and spoke to the biller she gave me a print out that showed two new no show fees had been added to my account both dated for the same day in january when I was seen in the office. She said that the office manager had added them onto my account because I had done a chargeback for $100 on my flex spending card. I told her that yes I had disputed the charge, but that my dispute was denied and that no chargeback was ever issued. They haven't shown me any proof that a chargeback was issued, but state that it was. I however contacted both my flex spending account and the cardholder services and both confirmed that no chargeback was ever done to the doctors office.

What can I do legally? Should I file a complaint with the medical board? BBB? Can I take them to small claims court and how do I go about it? They are doing so many different things wrong.

Doctor's office collecting money they know I won't owe.
Flex Spending dollars applied to something I didn't authorize.
No show fees that I know I don't have, but I only have phone records for one of the original two I was charged for.

Edit:
Also, is it legal for a doctor's office to only charge people due refunds (basically patients they have collected a deductible from that they then need to refund) for no show fees? Then not charging no shows to patients who are covered 100% by insurance or who only have an office visit copayment and aren't due refunds?
 
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ajkroy

Member
You say that you have never missed an appointment, but keep in mind that if you cancel 20 minutes before the appointment, they may not be able to fill it and must charge you the fee instead -- that may count as a "missed" appointment. Did this ever happen in your case?

If you are certain that you either attended every appointment or canceled each within a reasonable amount of time (24 hours or longer for Monday appointments), then stop using the phone. Only deal with these people in person from now on.

Find out who the office manager is and make an appointment to see him/her. Be calm. Explain that you were in the wrong for 1) not knowing how your insurance worked and blindly trusting the office who told you that you had to pay your deductible and for 2) not paying your previous copay on time. Ask for proof of the missed appointments. Each appointment booked should either have labs/notes associated with it or a no-show comment. They cannot arbitrarily add in "no show" appointments for days you did not actually have appointments. Explain that you paid with your FSA and there are very narrow regulations as to what you can use that money for -- no show fees are not allowed. If they insist, ask for a records transfer form so you can see another doctor. I personally would not continue to be a patient of an office that had these policies.

In the offices I used to manage, I would almost always give the first no show fee away. I would conspiratorially whisper to the patient something along the lines of, "You're never going to do this again, are you?" They usually walk away grateful and our attendance was very good. We only instituted our fees for the repeat offenders.
 

cbg

I'm a Northern Girl
If you are unable to resolve this with the doctor and/or his billing office, then you need to involve your insurance carrier. They will have an office called Provider Relations or something of the sort - they will be able to assist you. This will be separate from the number you have on the back of your ID card; you may need to call them and ask to be transferred. But Provider Relations (or whatever it is your carrier calls them) should be willing to intervene on your behalf, which will be much easier and result in a much faster solution than any of the potential suggestions you offer.
 

justalayman

Senior Member
One thing since you mentioned something about ethics and billing where the provider is aware there is no charge;

A provider does not know the details of every insurance policy of every patient. They have no idea where a patient stands regarding deductibles and out of pocket expenses. They have educated guesses with policies they deal with often but without a direct request to the insurance provider do not know the specifics of your policy and where you stand within your policy. Heck, some providers I visit have no idea what my co-pay is and either ask me or defer a demand to pay it until they file the claim.

There are hundreds if not thousands of insurance providers and within each provider there can be countless numbers of policies. No provider is going to know everything about every one.
 

Purrrl

Junior Member
You say that you have never missed an appointment, but keep in mind that if you cancel 20 minutes before the appointment, they may not be able to fill it and must charge you the fee instead -- that may count as a "missed" appointment. Did this ever happen in your case?

If you are certain that you either attended every appointment or canceled each within a reasonable amount of time (24 hours or longer for Monday appointments), then stop using the phone. Only deal with these people in person from now on.

Find out who the office manager is and make an appointment to see him/her. Be calm. Explain that you were in the wrong for 1) not knowing how your insurance worked and blindly trusting the office who told you that you had to pay your deductible and for 2) not paying your previous copay on time. Ask for proof of the missed appointments. Each appointment booked should either have labs/notes associated with it or a no-show comment. They cannot arbitrarily add in "no show" appointments for days you did not actually have appointments. Explain that you paid with your FSA and there are very narrow regulations as to what you can use that money for -- no show fees are not allowed. If they insist, ask for a records transfer form so you can see another doctor. I personally would not continue to be a patient of an office that had these policies.

In the offices I used to manage, I would almost always give the first no show fee away. I would conspiratorially whisper to the patient something along the lines of, "You're never going to do this again, are you?" They usually walk away grateful and our attendance was very good. We only instituted our fees for the repeat offenders.

I do not have no shows, and the cancellation policy for their office is 48 hours and I have always given that much if not more notice when rescheduling an appointment. I've worked in medical offices front and back and hospital inpatient accounting so I realize the importance of cancelling with notice and I've showed up to appointments with migraines so as to not fall into that category.

Part of the issue is speaking with the office manager or even scheduling an appointment with her. After multiple phone calls most of which were never returned I have now been to the office in person twice and still don't have an appointment to speak with her, however was told that the biller will speak to her on my behalf and someone will call me on Monday. It is doubtful that will happen when I've been promised several times before with no return call. I did get a copy of my medical records which are all dictated computer printouts and none of the pages list no show or cancelled appointments. I asked for a printout of all my appointments and was told they were ready and could pick them up with my medical records and when I asked for the printout because it wasn't with the medical records the biller relayed through the front office that only the office manager could give me a print out of my appointments, which is why I had the front office verbally give them to me so I could write them down. I have already moved myself, my father, and my husband to another practice.

I've tried the nice guy route which has led me down this path and now is why I'm posting here. I know what they are doing is wrong, but I need to know if it's legal or if there is any other recourse I have other than mailing a registered letter to the physician and then contacting the BBB, Medical Board etc...
 

Purrrl

Junior Member
If you are unable to resolve this with the doctor and/or his billing office, then you need to involve your insurance carrier. They will have an office called Provider Relations or something of the sort - they will be able to assist you. This will be separate from the number you have on the back of your ID card; you may need to call them and ask to be transferred. But Provider Relations (or whatever it is your carrier calls them) should be willing to intervene on your behalf, which will be much easier and result in a much faster solution than any of the potential suggestions you offer.
Thank you for the suggestion, I will look into it. It may be beyond that point currently, but I'll try anything to get this fixed.
 

Purrrl

Junior Member
One thing since you mentioned something about ethics and billing where the provider is aware there is no charge;

A provider does not know the details of every insurance policy of every patient. They have no idea where a patient stands regarding deductibles and out of pocket expenses. They have educated guesses with policies they deal with often but without a direct request to the insurance provider do not know the specifics of your policy and where you stand within your policy. Heck, some providers I visit have no idea what my co-pay is and either ask me or defer a demand to pay it until they file the claim.

There are hundreds if not thousands of insurance providers and within each provider there can be countless numbers of policies. No provider is going to know everything about every one.
Yes, their office had to look into my eligibility and benefits to know how much of my deductible hadn't been met and how much a specialist copayment is in order to ask me for it. It also tells them either online or if they call what is covered under an office visit and what applies to a deductible. I also worked for an office of the same specialty. They said they looked it up online, but they wouldn't show me a copy of their printout. Although I've been to many offices that didn't have a clue, nor even checked eligibility and benefits and wouldn't have collected the higher copayment had I not brought it up, this office isn't one of those.

Anytime I ask for something that will shed light on their error (or intentional) I am refused. The biller told me not to pay for my records until I picked them up because she didn't want the office manager to apply my payment for medical records to the two new no show fees (which I have a copy of the dates both on the same day on a day I was actually treated). She said she didn't agree with what was being done to me but that her hands were tied.
 

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