Insurance Fraud

[selfmade]

I've got a little issue with a dentist and an insurance today.

My wife found a dentist that is out of network. My out of network coverage is around 50%. Dentist assured her that he'll be able to adjust insurance claim so that insurance will pay 100%. She was wondering but agreed to the procedures. Dentist performed several procedures in 3 visits. All of these procedures were related to cleaning and healing of gum and pockets between gum and teeth. My wife signed paper with estimate that the procedures would cost $750
which is our liability. But dentist assured once again that we will pay $0.

Today I've received insurance statement with following procedures:
D0150 Comprehensive oral evaluation
D0210 Complex X-Ray Series
D3310 Root canal therapy - Anterior (tooth 07)
D3310 Root canal therapy - Anterior (tooth 08)
D3310 Root canal therapy - Anterior (tooth 09)

Fees charged: 2529. Insurance paid: 714. Our responsibility to the doctor: 1815.

None of root canal procedures have been performed on my wife. She had 3 root canals done about 5 years ago, but none at recent visits.

For me it looks like an insurance fraud.

Now questions:
1. If I report to insurance about the case how insurance will react?
2. What is the lowest amount of the claim to trigger insurance fraud investigation (in case if I report the case to insurance, will they act against the doctor or not?)
3. Was the information from the insurance claim entered into some central medical database and now my wife has 3 records for root canals? How that will affect insurability and premiums in future?
4. Can doctor cancel that claim?
5. In case of claim cancellation, can doctor bill me directly for actual procedures performed?

What would you advise me to do in this situation?

Upd. Quiz: What languages does doctor speak?

Comments

[ygam.livejournal.com]

I would call the insurance company and tell them the truth. Вор должен сидеть в тюрьме.

Upd. Quiz: What languages does doctor speak?

Russian?

[relf.livejournal.com]

ну так он ничего же не своровал - просто получил свои 700 с гаком

вот если он потребует заплатить 2529 - это будет фрод

[juan-gandhi.livejournal.com]

Don't do it.
Don't tell anything to your insurance (or else you are in trouble);
Don't ever go to a Russian dentist, or to a Russian car repair, or to a Russian car service... or anything like that.

I had called a Russian electrician recently, trying to figure out how much it would be to install a 240v socket. He said he's busy.

But Russian dentists... you save several hundred bucks, then you'll have to fix the teeth later again, paying with your money, your health, your suffering... It's as if you do not care much about your life.

[pontia.livejournal.com]

русские?
Это обычная практика русских докторов - они получают со страховки по максимуму, дурят разумеется.
Многие считают это плюсом, и ходят к русским именно из-за этого.
С вас требовать ничего не будут, им не надо, чтоб ты поднял скандал.
Мы к русским не ходим по этой причине - неохота мараться. Да и качество у них, как правило, хромает.
В любом случае - тебе это ничем не грозит,
мухлевал не ты. В любом случае можешь сказать(ежели вдруг чего), что не читал, что они там понаписали, терминологии не знаешь, вотэвер.

Ходите к американским, и спите спокойно:)

по существу

[relf.livejournal.com]

кстати, а зачем сразу в стаховую компанию обращаться - куда как проще позвонить в billing department конторы, где вы лечились, и высказать им свои претензии...

я как-то оспаривал одну счет за медицинские услуги - так в страховой компании первом делом спросили, не пытался ли я уладить это дело непосредственно с провайдером.

кстати, ответ на 4 - легко!
к нам один и тот же счет как-то в трех разных инкарнациях приходил (с разными кодировками и суммой для оплаты), пока он не стал таким, каким его обещали. после каждого "неправильного" счета мы просто звонили провайдеру и требовали уменьшить до величины обещанной суммы, они соглашались - и мы ждали новой версии счета... ;)

[kite-bitch.livejournal.com]

Oh my god, I can not believe the people up here who say "why do you care if he is screwing the insurance company". You people ARE ONE OF THE PROBLEMS we have with healthcare in this country today. Do call the insuranc company. Do tell them you did not have the root canal procedures done. They are not going to be able to actually do anything without the dentis re-billing the correct procedures. Talk to the doc's office. If you threaten them enough, they might generate an accurate bill and re-submitt to insurance.

And never never never again agree to receive services from a provider who is willing to committ insurnace fraud even if that means you will pay less for services.

[ah4uk.livejournal.com]

ta zhe fignya byla. V insurance kompanii sprosila esli vrach ne sdelal oshibku prosto i ne reshit vernut dengi, to che mol delat? Oni entuziazma ne proyavili. Pozvonila vrachu i prosto skazala shto on kozel i shtob nemedlenno vernul dengi. On skazal, shto mol oni prosto oshiblis i vs epometyat i esli hochu to vashe mne check lichno vernut:) HA! Ne hochu govoryu, hochu shtob obratno otpravili. Skazal sdelayut. POtom mne stalo len i ne do etogo i ya ne proverila otpravil ili net.