Is this just unethical or downright malpractice?

[solitaire]

Jurisdiction

Oregon

If a healthcare provider claims that they are "IN NETWORK" prior to a patient getting service and later after the service reveals they weren't, is that malpractice?

For clarity (you may already know this):
IN NETWORK means Dentist has already agreed to a pre-set rates and coverages as prescribed by the Insurance company.
OUT of NETWORK means ... rates are not negotiated and patients pay the difference plus coverages are usually not 100% (far less than in network coverages)

If healthcare provider lies (about their insurance status) to get a patient to come in for a service, I think we all can agree, it is unethical at best.
But is it also "malpractice"?
If the lie is captured in writing, is that sufficient evidence to get a judge to rule it as malpractice?

 

[justblue]

If a healthcare provider claims that they are "IN NETWORK" prior to a patient getting service and later after the service reveals they weren't, is that malpractice?

For clarity (you may already know this):
IN NETWORK means Dentist has already agreed to a pre-set rates and coverages as prescribed by the Insurance company.
OUT of NETWORK means ... rates are not negotiated and patients pay the difference plus coverages are usually not 100% (far less than in network coverages)

If healthcare provider lies (about their insurance status) to get a patient to come in for a service, I think we all can agree, it is unethical at best.
But is it also "malpractice"?
If the lie is captured in writing, is that sufficient evidence to get a judge to rule it as malpractice?

Did you check with your insurance to see if this dentist was in-network? You do realize that it is your responsibility to confirm that your doctor/dentist are in network...right?

 

[solitaire]

Yes. I did. As per insurance they were not in network just prior to service date (they were IN before and surprisingly got dropped). So, I called and asked the provider about it prior to service date.

Provider replied saying, it is just an administrative mistake and it will be fixed soon.
They also said in writing.. "This should not affect your appointment or payment."
I've been their patient for more than 10 years, I had no reason to doubt their words.

 

[adjusterjack]

Not malpractice.

"Detrimental Reliance." (Look it up.)

You can remind the provider of their written words and decline to pay. Then see what happens.

 

[Tax Counsel]

If healthcare provider lies (about their insurance status) to get a patient to come in for a service, I think we all can agree, it is unethical at best.
But is it also "malpractice"?
If the lie is captured in writing, is that sufficient evidence to get a judge to rule it as malpractice?

It is not malpractice. Malpractice is delivering professional services that fall below the minimal accepted standards of practice for that profession. How much you paid for the service is not a malpractice issue.

This is, instead, a contract law matter. Don't automatically assume the doctor lied about the insurance coverage. Insurance coverages are complex and it's quite possible for a doctor to think a particular insurer covers it when it doesn't, especially when dealing with multiple insurers.

Whether you have a good detrimental reliance defense depends on the case law (court decisions) in your state. If it's the doctor suing you, then a defense of detrimental reliance might fail, some states hold that you have the responsibility to verify the coverage yourself and if you didn't do that, you're out-of-luck. If you did contact the insurance company and it told you it was covered as in network, then you may have a good claim to sue the insurance company to have them pay you an amount that restores you to the position you'd have been in had the procedure actually been covered.

 

[cbg]

From what you say I would be willing to put money on the fact that they are currently in the process of renewing their contract with the insurance company. They are not lying to you; they have every expectation that when the dust settles they will be in network again, likely with no break. They may not even realize that they are technically out of network if the negotiations go on beyond the renewal date.

 

[zddoodah]

If a healthcare provider claims that they are "IN NETWORK" prior to a patient getting service and later after the service reveals they weren't, is that malpractice?

No.

If healthcare provider lies (about their insurance status) to get a patient to come in for a service, I think we all can agree, it is unethical at best.

Sure, but did you know that not all incorrect statements are lies?

But is it also "malpractice"?
If the lie is captured in writing, is that sufficient evidence to get a judge to rule it as malpractice?

No. Why would you think it might be malpractice?

Malpractice is the negligent rendition of professional services that is the actual and proximate cause of damage to the patient/client.

Provider replied saying, it is just an administrative mistake and it will be fixed soon.
They also said in writing.. "This should not affect your appointment or payment."
I've been their patient for more than 10 years, I had no reason to doubt their words.

So...where is the "lie"?

"Will be fixed soon" is an anticipatory statement that means, "as of the current moment it hasn't been fixed." "This should not affect your . . . payment" is not the same thing as "this will not affect your payment." At the time the above statements were made, you admittedly knew that that provider's in-network status had lapsed. Your response should have been, "should not affect or will not affect? If I get the service now, am I going to have to pay out-of-network rates? Should I just re-schedule until such time as this issue has been fixed?"