Health Insurance Fraud. My story.

[dave29]

How many of you have been the victim of insurance fraud? How many of you think you have been the victims of insurance fraud, but felt you did not have the resources to investigate? How many of you tried to investigate fraud but were met by a brick wall of resistance from all parties (Doctors, Medical Boards, Insurance Companies, Labs, etc who were involved). I fall into the last category.

This past April I decided to follow through with a referral to a pain clinic for trigger point injections for my ears (suffer from tinnitus and hyperacusis). This after 11 years of trying to find help for the problem (there is not much out there). At the visit, without prompting, it was suggested by the doctor that I try the medication Lyrica, which has been shown to help with nerve pain. I agreed to try, as well as a stellate ganglion nerve block (even though I wanted to try a trigeminal block -- not sure why he wanted to try stellate first). Anyways.

Long story short, the block did not work, the medication was extremely helpful, which was shocking to me.

Then the fun started. On a follow up visit to check on how to proceed with my treatment, I was asked to give a urine sample. I had no issues with this, as I signed paperwork knowing I would have to do this from time to time -- and knowing that there are all sorts of issues doctors face with diversion and addiction. I had informed my doctor of a remote history of drug abuse, and that I on occasion smoke pot. This was all notated in my records.

Moving on.

A few weeks later I received an EOB (Explanation of Benefits) from Cigna regarding work done by the lab that had processed the urine sample. The EOB was for $1806. $1806 dollars to test my urine. $80 was paid out to the lab by our insurance, $693 was removed from the remaining balance of our HRA (Health Reimbursement Arrangement), and the remaining $1000 or so was deemed my responsibility to pay, according to the EOB.

Needless to say, I became infuriated, and demanded an explanation, when I went in to cancel my next appointment. The front desk clerk told me others had complained about their EOB's, but that you didn't have to pay anything over what the insurance company had covered. I told them $693 had already been pulled from my HRA. They didn't seem to understand. I was put in contact with billing. I called and demanded an explanation. Very quickly I began to receive phone calls from the Doctor's office representative and from the CFO of the lab, all of whom seemed to be confused by the concept of an HRA.

For those of you who don't know an HRA works like this: You pay into your plan, and are provided with a certain amount of coverage via your insurer (in our case $1500 as a couple), then once that money is depleted, you pay out of pocket until you meet your deductible (in our case $4500). Due to this billing, we were now faced with having to pay out of pocket for the rest of the year. The companies that provide these plans get huge tax breaks, and those that buy into them do (hopefully) knowing that they only have a certain allowance before they are paying out of pocket. In other words: crap insurance.

Moving on.

I was promised an explanation, and a refund. The doctors office needed a few days to "figure out" what had happened. I received a call from the Dr's rep and he told me that they were advised by their attorneys to get a baseline on all their patients (urine test). This told me that everyone was having this done, and being billed the same (although their different health plans probably dealt with the billing differently). They told me they were testing "all the negatives". In other words, They were making sure I was not doing every drug known to mankind. They said that they were "first in Texas," and "Setting a Community Standard" -- and then proceeded to tell me they were going to stop doing that, and were completely changing their policy. Ok.

At no time would anyone provide me with specifics on the billing. The lab wanted to send me a check directly (via a third party biller, not even in their name), to cover the $693 taken from our HRA. I demanded they work with our insurance company. They stalled. Then they agreed after I put pressure on the doctor (there was a threat of passing this to the Medical Board for my state, and the Office of the Attorney General).

They made contact with our insurer and made arrangements.

The date came and went. Payment was not made. There was no further contact from the lab to our insurer (wife's employer), or to the insurance provider.

Things got nasty. I demanded an explanation for the specific items we were charged for. There were 13 line items labeled "Laboratory" on our EOB with no explanation. I could not get the lab, the doctor or even our insurance company to tell us what specifically was billed for. This remains the case.

Ultimately we got the lab to send us a check when we gave them a deadline before we took this to the medical boards/attorney generals for their respective states. The check was made out to Cigna, but had the wrong address. They never spoke with our HRA advocate, as we demanded. They never explained the billing as we demanded.

I have since taken this to the Medical board in Texas (Dr) and the Attorney General's office in California (lab). I am not optimistic anything will come of it, although the Texas Medical Board has it under review.

It is my firm belief we were the victims of upcoding or over billing of some sort. No one would provide answers. We are still waiting to see if the monies will be put back in our account to this day (been three weeks).

There is much more to this, but I am abbreviating (believe it or not) so that it is somewhat readable.

[Vinca]

1. Wow - and to think I bitch about the strip they have you pee on

and then charge $20. It sounds like "business as usual" fraud. Since it involves more than 1 state, maybe the U.S. Attorney General would be interested.

[lindisfarne]

2. Sounds like a malpractice case to me. The doctor did not explain the reason for the urine

test. Said urine test was not within standard medical practice for your medical issue. Sue for your time and suffering.

[dave29]

3. I am currently waiting to see if there is any traction with the medical board, etc

I am not optimistic. Failing action there, I will weigh other options.

The worst part of this is that none of the players to date have made any effort to explain the specific charges. That includes my wife's employer and our insurance company. We have a right to that information. But I guess that's what I should expect from this broken system.

As far as the lab and the Doctor go -- of course they won't give me specifics -- whatever they may be, they are indefensible.