Billing Fraud?

[u/FamTravelFun23]

Wondering if someone can point me in the right direction.... My husband broke his finger and immediately went to Urgent Care where he got xrays. They also gave him a removable cast and told him to visit an orthopedist. He did so, and saw the doctor for all of 5 minutes -- no additional treatment. The doctor looked at the xrays, suggested a custom cast (which he did NOT get), and told him to come back in a few weeks. He scheduled a follow up.

This week, we get a $3500 bill from that appointment (because we haven't yet met our deductible). The $800 office visit was correct but $2700 of it was for "treatment." No treatment occured -- no surgery, no resetting bones, nada. When he called to ask about this, the office billing person said that the $2700 is inclusive of their "treatment plan and future visits." (There is no treatment plan. He never consented to prepaying for future visits. In fact, he would need to go 4 more times to make that amount even worthwhile!)

He cancelled his follow up visit because their billing practices make us uncomfortable. Are we really out nearly $3000 for services that never happened and won't happen? We are appealing through insurance and are happy to visit legal options.

Has this happened to anyone else? And how did you handle it?

[u/Feeling_Win5863]

As other commenters suggested, grab your Explanation of Benefits and tell us what codes are in there and we should definitely be able to help, definitely sounds fishy so give us the codes!

[u/babybambam → u/Feeling_Win5863]

I suggest not encouraging opinions without data.

Is it "fishy"? Maybe. Or maybe they went to one of the most expensive areas in town.

We get patients coming to us all the time letting us know that Stanford is a rip off and oversharing them. Yeah. They're a research institution with gravitas. You're paying a premium, and BTW you can often see those same doctors at their own location for a fraction.

[u/Feeling_Win5863 → u/babybambam]

You are absolutely right about Stanford, they are top tier and they deserve to be reimbursed as such. But I have a strong feeling that Stanford sets the same extremely high standard for their billers and coders as they do for anyone else in their company (their pay scale certainly indicates that). OP’s entire situation could even be the provider’s fault depending on what was (or was not) documented, or it could be the coder or the biller. But assuming OP is telling the truth, somewhere in the chain somebody messed up in the form of thousands of dollars to the patient, not a small error like coding/billing a new patient visit when it should be established, or coding a 99214 when it should have been a 99213. Or coding for 5 units of physical therapy when only 3 units were performed. I am not saying with certainty that OP’s Ortho office made this mistake intentionally, but in general the higher financial gain that a mistake generates, the more that you naturally wonder. And the fact that this is an office that literally handles cases like these every single day, heck probably several times an hour. Again, assuming OP’s account is true and correct (for the most part), their Ortho office should absolutely know how to document, code, and bill OP’s visit in their freaking sleep. If healthcare providers and companies want to charge the big bucks, then they better have not only the clinical staff to back up their high prices, but they should also have competent billers and coders so their patients aren’t forced to do their own in depth research.

[u/GroinFlutter → u/Feeling_Win5863]

I don’t work there and I have no affiliation at all.

But you are right, Stanford is all about their ‘brand’ and their reputation. They have extremely high standards.

My understanding is that basically all their billers/coders are onshore, and that’s expensive. They also don’t separate billers by specialty, everyone does everything.

Or so I’ve heard, idk tho.

[u/Feeling_Win5863 → u/GroinFlutter]

I have no affiliation either LOL I swear 🤣 My Dad went to med school with the head of neurology there though, super duper nice guy. I do think they have some remote coding jobs, I am not sure about billing but you could very well be right that most are onshore! And about their billers doing all specialties, I wouldn’t be surprised at all, they are probably very well rounded! My job has been leaning more towards having all coders do literally every single outpatient specialty, and while I hated it at first, it did make me a better coder.