Linda Brandwin, R.N. Linda Brandwin is a registered nurse and a medical billing and claims specialist. For the past 10 years she has worked directly with insurance companies to give advice and guidance to the health care consumer. Readers may send email or write Linda Brandwin at 5500 Single Oak Hill Ct., Woodbridge, VA 22192.

Watch out for fraudulent doctor's bills
Sept 10, 2004

Q: A couple of months ago you had an article about doctors whose rates were higher than the insurance company paid. These doctors were listed as providers but refused to write off the additional costs. I thought I had clipped the article, but I am now unable to find it. Can you help me with my problem?

I was admitted to a hospital for an aneurysm that was bleeding. I was in a small local hospital and had to be transferred to a larger teaching hospital. We called our insurance company to receive authorization. They said it did not matter where we went due to the severity of my condition and that this was an emergency. My deductible and co-pay would be the same.

I have received over twenty bills for my hospital stay. My insurance covered them all. Every doctor has adjusted their bill according to the disallowed portioned as stated on my explanation of benefits. The only exception was for one doctor. This doctor told my insurance company that I got up out of my hospital bed, went to his office for a visit, and then returned to the hospital. Therefore, I must pay the $179.58 office visit bill. His charge was $260. My insurance told me they paid him $80.42. The doctor's statement said the insurance write-off was $80.42 and mentioned nothing about the payment from the insurance company. I have called this doctor's office five times to no avail. My insurance company said they would intervene, but they are with the government and on the government's timetable. In the meanwhile I just received a notice from the collection agency. What should I do?

A: There are many things going on with this claim. But everything comes down to one fact. If you never saw this doctor, then he submitted a fraudulent claim. In your condition it is obvious that you did not leave your hospital bed to see this doctor. Your insurance company paid him. Your insurance company's fraud department needs to be notified and they will handle this. But since your bill has already been sent to a collection agency, you should notify your state attorney general's office, your State Medical Board, and any insurance regulatory board your state has.

It is possible that this doctor did see you in the hospital. You may not have been aware of this visit due to the severity of your condition. If this is the case, this doctor should have billed the visit as a hospital visit or hospital consultation and not an office visit. You need to call the hospital records department and explain your problem. Ask them to check your hospital chart and verify if you were indeed seen by this doctor for the stated date of service he claims. If this is the case, then explain the error to the doctor's billing department and your insurance company. And be sure the doctor's office removes you from the collection agency. His bill needs to be resubmitted with the correct charges and billing information.

Hopefully, if this doctor's bill is resubmitted and reprocessed, the doctor's office will post the payment correctly along with the appropriate write-off. If they do not write-off the disallowed, you will have to start all over again by calling the doctor's office, the insurance company, and any state offices which may be of assistance to you.

The first and foremost issue to resolve is checking with the hospital to see if this doctor really saw you or not. You need to determine if this is fraud or just a mistake. Then you will be able to figure out which steps you need to take.