Can doctors be selective in submitting claims to insurance company?

Question

I was charged a fee for a service upfront stating insurance do not cover this service, but turns out it was not true, insurance company covers it. I called the doctor's office asking them to submit the claim, they delayed the process by mailing the claim. After the claim was paid I waited for them to call me stating they will issue a refund but I did not get a call. I disputed the charge with my credit card company.

I could change my doctor but I started a treatment so I don't think another doctor will take me and they refused treatment stating I need to pay them in cash for the transaction dispute fee and for services going forward. Dr said they don't submit claims for this service because insurance does not cover full cost of the service. If the amount paid to them is not acceptable than they should not accept the insurance. Why lie to patients?

Can they be selective and submit claims that are profitable to them and on others they lie and charge patients instead of billing the insurance? Is there anyone I can complain about their shady practices?

Answer 1

Not all doctors submit claims to insurance companies. Some only submit claims to some insurance companies.

I prefer ones that submit claims to my insurance company, and then bill for the balance if the amount I am responsible is more than a flat co-payment.

When I have had double payment due to confusion over the approved amounts They have always responded to a request to pay me back. In some cases they have given us a credit, but that can lead to confusing when the number of visits is large and it can be confusing because multiple claims are in different stages.

Disputing the charge was the nuclear option. They had to respond to the credit card company, and they now have a mark on their record. Not what they wanted.

How they submit claims depends on their relationship with your insurance company.

If they are considered out-of-network, they most likely leave all the claims paperwork to you, after collecting the amount you have negotiated.

If they are viewed as in-network, the deal dictates who files and how much they can charge you and the insurance company for certain procedures, and is silent about other procedures. This is where you situation falls into. A doctor may be able to perform services that are not covered by your insurance.

We did drop one doctor because they told us procedure X wouldn't be covered, and we paid with the Health savings account card. Later we realized the fact that they didn't include it on any of the paperwork to the insurance company meant we had no proof it was for a medical expense. They failed to understand the issue, and later we switched doctors.

We always ask them to submit everything and see what is covered, sometimes you get lucky.

Answer 2

If a doctor gives you incorrect information about what your insurance covers to induce you to pay them more for covered services, you should file a grievance with your insurance company. This is almost certainly a violation of their contract with your insurance company and your insurance company has the leverage to compel them to make it right.

Unfortunately, this will almost certainly destroy any trust between you and the doctor, but it sounds like that's already gone. Your insurance company can help you find another doctor.

You can try going to the doctor's office and talking to whoever manages that office. Explain to them the situation and that you would like to continue to use them, but they gave you incorrect information and they have to make it right. Otherwise, they have a credit card dispute, a grievance, and they lose a patient. You might be surprised at how reasonable they might be. Or not.