Reporting Insurance Fraud (Should I do it?)

Sharpieman · 05-10-2005, 08:53 PM

A few months ago I gave a ride to my girlfriend to a dentist (a friend of my girlfriends family). Fast-forward to a couple of weeks later and she had to have some surgery at the same place. Well I find out from my girlfriend's mom (someone I totally dislike, but thats beside the point) that the dentist charges not just one of their insurance carriers, but 3, because her mom has 2 jobs and her dad has another (the mom and dad are divorced). When I found this out I got pretty mad, but stayed cool in front of my girlfriend and her family. I konw that in the end its me and my family that gets hurt by insurance fraud, since insurance companies need to increase the premiums etc. etc. Well now I have a dilemma, since I want to report the fraud to authorites, but I don't want my girlfriend or family to get in trouble. Since they could maybe be seen as accomplises since they know about the fraud and haven't done anything about it. So now I'm stuck between a rock and a hard place because its both a moral dilemma and a case where I don't want anyone but this dentist to get in trouble.

Comey · 05-10-2005, 08:55 PM

I'm not too keen on this stuff, so please help me out. Why would her family get in trouble?

Sharpieman · 05-10-2005, 09:02 PM

Well they know about it and told me. Plus I guess its kind of a hush-hush issue, which no one is supposed to say anything about it. I don't know, really, maybe they can't get in trouble. But I'm not entirely sure.

Eaglesfan27 · 05-10-2005, 09:03 PM

The question is does he charge all 3 insurance companies independantly or not. What I mean is that I see some patients who are charged to their primary insurance for services that I render, and the percentage that the insurance doesn't cover is charged to a secondary insurance. That is not insurance fraud. Both insurance companies know that I'm charging both of them, one 66% for example and the second 34%.

However, if s/he is getting paid in full or greater than the value of the services by all 3 insurance companies that is fraud. Insurance Fraud by doctors is usually a federal crime (because it usually involves transactions across state lines) and is a very serious offense. I doubt your girlfriend or her family would get in trouble unless they are telling the doctor to triple charge and getting some sort of reward for this.

DaddyTorgo · 05-10-2005, 09:06 PM

report it. let an investigator sort it out. there shouldn't be any reason for your GF's family to get in trouble i wouldn't think and I also don't think there's any way they could know it was you that reported it

Sharpieman · 05-10-2005, 09:10 PM

Quote:

Originally Posted by Eaglesfan27

The question is does he charge all 3 insurance companies independantly or not. What I mean is that I see some patients who are charged to their primary insurance for services that I render, and the percentage that the insurance doesn't cover is charged to a secondary insurance. That is not insurance fraud. Both insurance companies know that I'm charging both of them, one 66% for example and the second 34%.

However, if s/he is getting paid in full or greater than the value of the services by all 3 insurance companies that is fraud. Insurance Fraud by doctors is usually a federal crime (because it usually involves transactions across state lines) and is a very serious offense. I doubt your girlfriend or her family would get in trouble unless they are telling the doctor to triple charge and getting some sort of reward for this.

No, I understand the difference. She charges all three insurances in full. I'm actually surprised that she hasn't been investigated or caught yet. It would be scary to think that this kind of thing is frequent.

MrBug708 · 05-10-2005, 09:15 PM

After a bad accident, my chiropractors wanted to charge me triple their normal rate because the insurance company was going to pay and she about killed the chiropractor

lynchjm24 · 05-10-2005, 09:25 PM

Quote:

Originally Posted by Eaglesfan27

The question is does he charge all 3 insurance companies independantly or not. What I mean is that I see some patients who are charged to their primary insurance for services that I render, and the percentage that the insurance doesn't cover is charged to a secondary insurance. That is not insurance fraud. Both insurance companies know that I'm charging both of them, one 66% for example and the second 34%.

However, if s/he is getting paid in full or greater than the value of the services by all 3 insurance companies that is fraud. Insurance Fraud by doctors is usually a federal crime (because it usually involves transactions across state lines) and is a very serious offense. I doubt your girlfriend or her family would get in trouble unless they are telling the doctor to triple charge and getting some sort of reward for this.

It's called Coordination of Benefits (COB) by most insurance carriers.

Are they getting EOBs from the different carriers that show that they are really making the payments?

Most dental policies (especially PPO/Indemnity) have very low yearly maximums, say $750 for the year. It might very well be that they have to send it to all three carriers, it then becomes a COB issue and the secondary coverage won't pay anything until the primary carrier reaches their maximum.

It probably isn't fraud, check the actual explanations of benefits to see what the payments truly are. If they aren't receiving them, it's probably because there is no payment from a carrier on a claim - they don't send out EOBs for zero payments.

If the EOB's look fishy, then you can probably contact a fraud hotline without even revealing your identity. I work for the one of the major carriers and could dig up the number if you decide you want to make a call. Unless the family is getting kickbacks there isn't going to be any legal ramifications for them.

Eaglesfan27 · 05-10-2005, 09:31 PM

Quote:

Originally Posted by lynchjm24

It's called Coordination of Benefits (COB) by most insurance carriers.

Are they getting EOBs from the different carriers that show that they are really making the payments?

Most dental policies (especially PPO/Indemnity) have very low yearly maximums, say $750 for the year. It might very well be that they have to send it to all three carriers, it then becomes a COB issue and the secondary coverage won't pay anything until the primary carrier reaches their maximum.

It probably isn't fraud, check the actual explanations of benefits to see what the payments truly are. If they aren't receiving them, it's probably because there is no payment from a carrier on a claim - they don't send out EOBs for zero payments.

If the EOB's look fishy, then you can probably contact a fraud hotline without even revealing your identity. I work for the one of the major carriers and could dig up the number if you decide you want to make a call. Unless the family is getting kickbacks there isn't going to be any legal ramifications for them.

I'm terrible about dealing with the business side of things. You explained it much better than I did

Galaxy · 05-10-2005, 09:36 PM

Quote:

Originally Posted by Eaglesfan27

I'm terrible about dealing with the business side of things. You explained it much better than I did

Prolly way many doctors have Insurance managers to deal with it.

Always been curious, do you learn about this stuff at all in Med school?

Eaglesfan27 · 05-10-2005, 09:39 PM

Quote:

Originally Posted by Galaxy

Prolly way many doctors have Insurance managers to deal with it.

Always been curious, do you learn about this stuff at all in Med school?

At least at my school, they had an elective which I took to learn about insurance and business options. However, considering it was tucked in between OB/GYN and Surgery (my two busiest rotations), I hardly remember anything from it except for the bare basics.

Greyroofoo · 05-10-2005, 09:52 PM

Well if you want to do the right thing, report it. Its pretty black and white here.

If you want to continue getting lucky, don't.

I guess it depends where your priorities are.

Sharpieman · 05-10-2005, 10:14 PM

Well I guess there won't be any hurt in reporting it.

Mustang · 05-11-2005, 08:34 AM

If you haven't voiced your complaints to your girlfriend then there probably is no way that it will be traced to you if you report it..

Ksyrup · 05-11-2005, 08:38 AM

Yes, you should.

Passacaglia · 05-11-2005, 09:49 AM

You don't want to piss off anyone who takes a knife to your gums.

Bee · 05-11-2005, 10:09 AM

I'd be surprised if this is anything more than a misunderstanding on how the doctor is turning in the charges to the insurance companies. When you have multiple insurance policies, one is always primary and the others are secondary. All insurance companies involved know this and there's pretty strict observance of what's being paid and charged. The only way the doctor could get away with charging all insurance companies full price would be working in conjunction with the patient who would have to lie on their benefits forms about having other insurance coverage and even then they'd most likely get caught through general audits.

05-10-2005, 08:55 PM	#2
Comey College Starter Join Date: Nov 2003 Location: CT via PA via CA via PA	I'm not too keen on this stuff, so please help me out. Why would her family get in trouble? __________________

05-10-2005, 09:02 PM	#3
Sharpieman Greatly Missed. (7/11/84-06/12/05) Join Date: Oct 2002 Location: Palo Alto, CA	Well they know about it and told me. Plus I guess its kind of a hush-hush issue, which no one is supposed to say anything about it. I don't know, really, maybe they can't get in trouble. But I'm not entirely sure. __________________ Better to remain silent and be thought a fool than to speak out and remove all doubt.

05-10-2005, 09:03 PM	#4
Eaglesfan27 Hall Of Famer Join Date: Nov 2002 Location: New Jersey	The question is does he charge all 3 insurance companies independantly or not. What I mean is that I see some patients who are charged to their primary insurance for services that I render, and the percentage that the insurance doesn't cover is charged to a secondary insurance. That is not insurance fraud. Both insurance companies know that I'm charging both of them, one 66% for example and the second 34%. However, if s/he is getting paid in full or greater than the value of the services by all 3 insurance companies that is fraud. Insurance Fraud by doctors is usually a federal crime (because it usually involves transactions across state lines) and is a very serious offense. I doubt your girlfriend or her family would get in trouble unless they are telling the doctor to triple charge and getting some sort of reward for this. __________________ Retired GM of the eNFL 2007 Super Bowl Champion Philadelphia Eagles (19-0 record.) GM of the WOOF 2006 Doggie Bowl Champion Atlantic City Gamblers. GM of the IHOF 2019 and 2022 IHOF Bowl Champion Asheville Axemen.

05-10-2005, 10:14 PM	#13
Sharpieman Greatly Missed. (7/11/84-06/12/05) Join Date: Oct 2002 Location: Palo Alto, CA	Well I guess there won't be any hurt in reporting it. __________________ Better to remain silent and be thought a fool than to speak out and remove all doubt.

05-11-2005, 08:34 AM	#14
Mustang Grizzled Veteran Join Date: Oct 2000 Location: Wisconsin	If you haven't voiced your complaints to your girlfriend then there probably is no way that it will be traced to you if you report it.. __________________ You, you will regret what you have done this day. I will make you regret ever being born. Your going to wish you never left your mothers womb, where it was warm and safe... and wet. i am going to show you pain you never knew existed, you are going to see a whole new spectrum of pain, like a Rainboooow. But! This rainbow is not just like any other rainbow, its...

05-10-2005, 09:06 PM	#5
DaddyTorgo Hall Of Famer Join Date: Oct 2002 Location: Massachusetts	report it. let an investigator sort it out. there shouldn't be any reason for your GF's family to get in trouble i wouldn't think and I also don't think there's any way they could know it was you that reported it

05-10-2005, 09:15 PM	#7
MrBug708 Head Coach Join Date: Apr 2001 Location: Whittier	After a bad accident, my chiropractors wanted to charge me triple their normal rate because the insurance company was going to pay and she about killed the chiropractor

05-10-2005, 09:52 PM	#12
Greyroofoo Pro Starter Join Date: Nov 2003 Location: Alabama	Well if you want to do the right thing, report it. Its pretty black and white here. If you want to continue getting lucky, don't. I guess it depends where your priorities are.

05-11-2005, 08:38 AM	#15
Ksyrup This guy has posted so much, his fingers are about to fall off. Join Date: Nov 2000 Location: In Absentia	Yes, you should. __________________ M's pitcher Miguel Batista: "Now, I feel like I've had everything. I've talked pitching with Sandy Koufax, had Kenny G play for me. Maybe if I could have an interview with God, then I'd be served. I'd be complete."

05-11-2005, 09:49 AM	#16
Passacaglia Coordinator Join Date: Oct 2000 Location: Big Ten Country	You don't want to piss off anyone who takes a knife to your gums.

05-11-2005, 10:09 AM	#17
Bee Pro Starter Join Date: Oct 2000 Location: Fairfax, VA	I'd be surprised if this is anything more than a misunderstanding on how the doctor is turning in the charges to the insurance companies. When you have multiple insurance policies, one is always primary and the others are secondary. All insurance companies involved know this and there's pretty strict observance of what's being paid and charged. The only way the doctor could get away with charging all insurance companies full price would be working in conjunction with the patient who would have to lie on their benefits forms about having other insurance coverage and even then they'd most likely get caught through general audits. Last edited by Bee : 05-11-2005 at 10:10 AM.

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