My doctor is defrauding insurance company?

Question

I went to see two different gynecologists in same county but different cities within 1 month for EXACT SAME check-up/test(1st trimester pregnancy). Instead of charging the insurance the same or similar amount, one doctor charged $680 while the other doctor charged $130. Is one doctor defrauding the insurance or is this normal variance between different doctors? I live in Los angeles county

Answer 1

If you went twice for the exact same check up, then didn't YOU defraud the insurance co????

Answer 2

In theory, a doctor can CHARGE whatever they want. It's what they get PAID is where the difference lies. When a doctor is contracted to an insurance company, they agree to accept whatever amount the insurance pays for whatever service they perform.

The only way I can account for the huge difference is to ask this: had you ever seen the doctor that charged the $680 before? Often, if you're a new patient, they charge significantly higher for your first visit because they're supposed to be getting your entire health history. Also, "specialists" charge a LOT more than "regular" doctors, so if that one was listed anywhere as any kind of specialist, that can also account for the price difference.

Answer 3

Can't tell unless you know exactly what the listed charges are for. It's not a crime to charge different prices, the insurance company may only pay a flat rate for certain procedures anyway, no matter what the doctors ask for. If the doctor is saying he did things that he didn't, you will know when the insurance company sends you your version of the paperwork, then you can turn him in if necessary

Answer 4

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 5

Totally normal. It has to do with the agreements between individual doctors and the insurance company. Because insurance typically pays a lesser amount than billing, many doctors charge a high billing amount thinking that they may end up getting a higher amount from the insurance company.

Answer 6

Some people are specialists. Some insurances pay set amounts "in system". Some doctors are participating
providers and some aren't. The big question is how much did you have to pay, and will you be reimbursed by insurance?

Answer 7

Depends on what the demand of the higher paying doctor. That might be HIS usual fee. However it's my experience that insurance companies have a ceiling for what they actually pay any in network doctor. So they probably won't pay him $680.00.

Answer 8

They are both cheap at twice the price, some doctors charge that much to take out a splinter.

Answer 9

Could it be one is an HMO doctor and the other is a private practise? Or maybe the reimbursement rates are different for a Preferred Provider vs. a Non-covered provider?
Reimbursement rates (a.k.a. charges) are based on the procedures billed and the diagnosis submitted. One could have listed you as a 1st trimester (congrats!) and the other possibly as a High-risk pregnancy. As for procedures, one could have submitted for general blood draws and the other for a triple screen test (too lengthy to go into here).

Answer 10

Most reimbursement is based on zip code. Yep. I worked on a few projects for a very large insurance company. It is not unusual for the rates to be different even for the same specialist.