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Doctor refuses to refund money according to insurance PPO contract

Discussion in 'Health Insurance, HMO, HIPAA & Disability' started by tstrat, Feb 25, 2010.

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  1. tstrat

    tstrat Law Topic Starter New Member

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    I have an issue with a doctor and I am not sure what my options for proceeding. I am looking into speaking with an attorney locally but would very much appreciate any pointers or alternative routes to take to get this resolved. I'll try to keep it short but it is a complicated situation...

    My wife has a chronic illness that we have been treating for the past five years. We live in Illinois. In September of 2008 we met with a doctor and surgeon in Texas regarding a new procedure that was being done and they recommended that she have the surgery. We have BCBS PPO insurance and the Surgeon was a participating provider in the network. When meeting with the surgeon, we are told that they will begin by submitting a pre-authorization to the insurance company and that the cash price for the surgery is $15,000 if the insurance does not pay.

    At this point she had met all of her deductible and her max out-of-pocket cost for the year so if approved the insurance would pay at 100%. We scheduled the surgery for December of 2008.

    The pre-authorization was approved by BCBS for all of the codes and they sent letters to the surgeon stating that the codes were approved but that it was "not a guarantee of payment" (obviously). The surgeon's office cited this statement saying that we had to pay up front and get reimbursed by the insurance company. I knew that this was not correct and verified with BCBS that he was in network and that he technically could not charge us anything up front. They called and explained this to the surgeon's office and faxed information showing that her deductible and out-of-pocket had been met for the year. They still refused to do the surgery until we paid out of pocket. At this point we were desperate to have the surgery done and also needed to have it done before the end of the year to save several thousand on the deductible and out-of-pocket that would reset in January 2009. I verified with BCBS that they were not allowed to charge us more than the prices set in the contract and that we would be refunded provided that all of the codes were approved. I also had them enter a complaint in the system because the surgeon's office wanted us to pay up front.

    My parents loaned us the $15,000 for the surgery and we had it done in December 2008. The surgeon's office completed a claim form and gave it to us to submit to the insurance. After several rounds of corrections, I submitted it. The claim went through BCBS several times for different reasons, every time processing as out of network. It turns out that a big part of the problem was that they put the wrong provider ID on the claim form. BCBS got corrected forms from the surgeon's office, which meant that they had to pay the office directly rather than sending the check to us.

    All of the codes were approved and the amount paid was $4,427.57. Our patient responsibility is $0.00. I talked to BCBS and verified that the surgeon would need to refund us the $4400 in addition to the amount that we overpaid, adding up to $15,000. I talked to the surgeons office and they said that they would only refund the $4427 that the insurance paid them. I then had BCBS explain to them that they needed to refund the full amount and they still refused, stating that we had agreed to pay the cash price. Note that we did not sign anything agreeing to this or agree to it verbally. It was just presented as the cash price "if insurance does not pay." After a few months and several calls I was able to get the check for the $4427 refund from the surgeon's office. At this point I am on a first name basis with the BCBS representatives.

    BCBS promised to take care of the issue and it was escalated through several levels. They were not able to get the surgeon's office to respond to their requests. Apparently sometime during this process the surgeon stopped participating in the PPO because he is no longer an in-network provider. BCBS said that this is also complicating the issue (I'm guessing because it gives them less leverage if because they can't threaten to drop him from the network).

    I told BCBS that I was considering taking legal action on my own and the representative recommended that I do this. She said that they were still working on it but that she wasn't sure how long it could take or what actions they would take next. It didn't sound promising at all.

    All of this and the surgery actually made things worse!

    Other than talking to an attorney locally, are there any other steps that I should take? Is there a state board that I should file a complaint with, and if so should it be with Texas or Illinois? I would like to get back some of the interest that I have paid in all of this time waiting to get reimbursed... is that something that I might have a chance at or should I forget about it and just try to get the rest of the original money back?

    Thanks for any help you can offer!
     
  2. army judge

    army judge Super Moderator

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    Physicians have no obligation to take insurance payments.
    They often do for the reasons you stated.
    This physician no doubt knew that he was leaving the BC/BS network.
    You gave in to his demands to get the surgery.
    What he did isn't illegal, although I consider it somewhat unethical.

    This surgeon sounds like one of those bariatric or cosmetic surgeons.
    As he/she practices in Texas, a complaint could be brought before the Texas medical Board.
    I don't see a cause of action, however.

    As far as getting interest, it isn't enough to worry about these days, is it?
    You got all this crook is going to give up, $4,500.
    And, that was struggle, wasn't it?
    Some of these bariatric/cosmetic surgeons are sharks.

    I doubt that he'll give you back $15,000, in lieu of taking $4,500 from BC/BS?
    He doesn't care about being in a managed care practice, he's got a few cash cows!
    I wouldn't do it, but it works for him.

    That is why the hard sell was put on you in the first place.
    You shouldn't have given him a dime, and refused to have anything done.
    You'll never see that 15 grand again.

    You can use the $15,000 as tax deduction, if that helps.
    If the surgery has caused your wife issues, that could be a cause of action for negligence or medical malpractice.
    Otherwise, I'd say you're out of luck and 15 grand!

    But, BC/BS is still working on the bum.
    They might be your best bet in this case.
    It isn't enough money to hire an attorney to recover.
    Most attorneys would want at least $7,500 to represent.
    There is no guarantee in that, either.
    I'd suggest, you be patient, stay in the good graces of BC/BS; and let them wear him down.

    I'm sure BC/BS doesn't like this type of play.
    If they lose control of too many of these guys, their ox gets gored.
    I'd bet on BC/BS getting you all of your money back at no additional cost to you.
    And, all that happens without laying out another 7 grand to collect 15 grand!
     
    Last edited: Feb 25, 2010

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