Ask Me Help Desk - Possible Shady Business.

Hope this is the right place for this. This has been bugging me for some time now, so I am finally asking.

I see a specialist Dr and he has me on 3 prescription meds. One of these meds must be refilled every month either with a paper prescription or a call-in by the Dr's office, under the law it cannot be refilled any other way. Is it legal for him to charge for an office visit when he just simply refills my prescription and does NOT see me physically? I have been charged for approximately 6 to 8 visits that I was NOT actually seen. He does this with several other patients as well, I am by no means the only one. He happens to not accept my particular insurance so I have been paying out of my own pocket for all this, but he accepts other insurance including TriCare (federal gov insurance) and I know he's billing these insurance companies and not seeing the patients just as he is doing with me.

Is this illegal, and if so what should I do, who do I go to? I'd like to get my money back if this is wrongdoing on his part, and I'm sure all these insurance companies would like to know that they've been defrauded if it's the case here. The more and more I think about it, the more it seems just plain WRONG.

Thanks for any help.

To my knowledge, it IS wrong to bill you for an office visit when he's simply calling in a Rx for you. Because you are self-pay, it may be easy for him to submit a bill without fear of scrutiny. (Insurance companies are capable of audits, denials, etc. so a doctor would be very careful in dealing with these)

You say you KNOW he's doing this to others? How do you know? I recommend just dealing with your own case here and not getting involved with others.

Call your doctor's office and ask for an "Itemized Statement" This is a broken down bill that should provide all the details you need regarding what he billed your insurance, when.

If you find discrepancies, call a local lawyer or the state medical board and ask them to review what you've found. They'll tell you what to do from there.

On that note: Ask your insurance company if any other physicians of his speciality are covered. Its time you transfer your care if possible.

If this is illegal and fraudulent, then why shouldn't something be done to report this to insurance companies? He's easily making hundreds of thousands of dollars a year in fraud if this is in fact illegal, and innocent people are paying for this. Many of his clients are government-insured people, so in effect YOU and all other tax payers are making him rich.

I live in a rural area, and unfortunately this is the only Dr around for this specialty. But... since he has already diagnosed me, and since I have been on the meds he has prescribed for quite a long time with success, I am going to bring the meds to my next appointment with my GP and tell him the situation with this Dr and I hope my GP will just continue me on these meds. This is my only option as far as I can see, aside from driving for hours to the next nearest specialty Dr.

When I speak with my GP, hopefully he can tell me for sure if this Dr is doing fraudulent business and perhaps he can tell me what should be done about it. I'm assuming that since I had paid out of my own pocket I would have to sue the Dr in small claims to get my money back. But I wonder if it would be better to get ALL of the people who have paid out of pocket to come together against the Dr?

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Originally Posted by passmeby

If this is illegal and fraudulent, then why shouldn't something be done to report this to insurance companies? He's easily making hundreds of thousands of dollars a year in fraud if this is in fact illegal, and innocent people are paying for this. Many of his clients are government-insured people, so in effect YOU and all other tax payers are making him rich.

First of all, because it is not your business and you cannot prove what his other patients bills may entail. Its one thing to talk to someone you believe is being taken advantage of and ask them to report it. But frankly, you cannot get involved because you do not have the ability to provide the insurance companies with sufficient information. Those companies receive thousands of complaints from each doctor that's ever practiced, I assure you. They will not investigate the claims of someone that is not even covered by their company. On that note, if YOU report this to a lawyer (since your insurance does not participate with this doctor) the ball will get rolling and an audit will most likely take place. This could possibly lead into other companies auditing his practice as well.

Quote:

I live in a rural area, and unfortunately this is the only Dr around for this specialty. But... since he has already diagnosed me, and since I have been on the meds he has prescribed for quite a long time with success, I am going to bring the meds to my next appointment with my GP and tell him the situation with this Dr and I hope my GP will just continue me on these meds. This is my only option as far as I can see, aside from driving for hours to the next nearest specialty Dr.

This may be a good option. Depending on the meds, your GP may not want to take part, but it's a good idea to talk with him about it.

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When I speak with my GP, hopefully he can tell me for sure if this Dr is doing fraudulent business and perhaps he can tell me what should be done about it. I'm assuming that since I had paid out of my own pocket I would have to sue the Dr in small claims to get my money back. But I wonder if it would be better to get ALL of the people who have paid out of pocket to come together against the Dr?

Consult a lawyer, not your GP. Your GP will not be very knowledgeable himself (doctors hire support staff to do billing--they rarely have a FULL understanding of how it works). Also, doctors of any specialty are very hesitant to speak ill of other doctors.

Regarding having others come together against this doctor, again that is a lawyers place to deal with. A class action lawsuit like this would go beyond small claims court, but a proper lawyer can counsel you further on that. That process typically takes 2 - 5 years if you can believe it.

(just so you are aware, I've worked in healthcare for 13 years. I'm no legal expert, but I know a good bit about these things)

Thanks for your post. I'm not saying I persoanlly want to get involved in other's cases, all I am asking is how to tip off the insurance companies that fraud is going on and of course THEY would do the investigating.