My doctor is defrauding insurance company?

Question

I went to see two different gynecologists in same county but different cities within 1 month for basically same check-up/test(1st trimester pregnancy). Instead of charging the insurance the same or similar amount, one doctor charged $600 while the other doctor charged $300. Is one doctor defrauding the insurance or is this normal variance between different doctors?

Answer 1

First of all, insurance companies do NOT pay what doctors charge. Doctors can only charge using CODES, which are written in a huge book and pretty standard. If they charge with the same code but one is twice as much, one of them is probably off, but that's not a fraud, and they will get paid the same amount.
It's possible one doctor charges a higher code, if he/she feels he/she spent enough time with you to justify it (office visits are based on length and complexity). How we code a visit is not 100% standard, as every doctor sees a case from a different perspective.
It's still possible that you think 2 visits are the same but one ran an additional test or procedure. Look closely at your Explanation of Benefits, and you will see how much the doctors got PAID.
Honestly, these days MD's mostly are underpaid, especially with HMO's. I could charge $200 and get zero. They have all kinds of way of denying payment. Fraud...ha...

Answer 2

I don't know if there are standard charges for the same procedures or office visits, or if there are allowances for certain conditions that would make one doctor charge twice as much as the other one. If there is fraud, it will soon be discovered, as insurance companies are always on the lookout for such things, and even if they were not, others could report him or her for higher-than-average charges without due cause. It's really hard to say for sure, whether or not fraud is the issue. But if it were me, I'd stay with the cheaper doctor.

Answer 3

This is a normal variance between doctors. Doctors typically gets paid by a contracted rate from the insurance company. How much they charge do not affect how much the insurance pay them.