What would you do? (Suspected Waste/Fraud/Abuse)

[Limozine]

Here's the situation: my father is on an MAPD plan with dental coverage. I also represent the carrier he's with. So back on March 8 he needed to have two teeth extracted. I found a network provider in our local area to do the extractions. On the day of service, they charged us $264. I objected, stating that as a network provider they should handle all claims and there should be no co-pays on these extractions. They insisted that it was a formality and that they would reimburse us as soon as the claim was paid, so I paid the $264.

A couple of weeks go by and I don't hear anything. I reach out to the provider and they say they haven't been paid by the carrier yet. I wait a few more weeks and still nothing. Today I reach out to the carrier, who informs me that a check was mailed out to the provider on 4/11. So we're now 18 days past the date the check was cut, and I've heard nothing from the provider. I call the provider, who tells me that refunds are issued every Friday and that ours will be issued this coming Friday (without explaining why three Fridays have already passed without the refund being issued).

Here is my suspicion: I wonder if the provider is charging all network patients a similar upfront charge, and only refunding those savvy enough to expect it. I can't prove it (yet) but I want to make sure my clients aren't being taken advantage of by bad actors.

 

[GoPokes]

I've had similar suspicions for awhile. I have talked to various beneficiaries with dental benefits, who are still paying a fair amount for the services while using the plan benefits. Im also curious how some of the dental benefits can get used up so quickly, for rather small services.

 

[sshafran]

Here's the situation: my father is on an MAPD plan with dental coverage. I also represent the carrier he's with. So back on March 8 he needed to have two teeth extracted. I found a network provider in our local area to do the extractions. On the day of service, they charged us $264. I objected, stating that as a network provider they should handle all claims and there should be no co-pays on these extractions. They insisted that it was a formality and that they would reimburse us as soon as the claim was paid, so I paid the $264.

A couple of weeks go by and I don't hear anything. I reach out to the provider and they say they haven't been paid by the carrier yet. I wait a few more weeks and still nothing. Today I reach out to the carrier, who informs me that a check was mailed out to the provider on 4/11. So we're now 18 days past the date the check was cut, and I've heard nothing from the provider. I call the provider, who tells me that refunds are issued every Friday and that ours will be issued this coming Friday (without explaining why three Fridays have already passed without the refund being issued).

Here is my suspicion: I wonder if the provider is charging all network patients a similar upfront charge, and only refunding those savvy enough to expect it. I can't prove it (yet) but I want to make sure my clients aren't being taken advantage of by bad actors.

Providers must be fully trusted and never questioned!

After all, they have medical degrees. Sure they are not capable of milking a system to fund their new BMW... Or (in the case of a dentist) their new office building!!

 

[Limozine]

I've had similar suspicions for awhile. I have talked to various beneficiaries with dental benefits, who are still paying a fair amount for the services while using the plan benefits. Im also curious how some of the dental benefits can get used up so quickly, for rather small services.

Providers must be fully trusted and never questioned!

After all, they have medical degrees. Sure they are not capable of milking a system to fund their new BMW... Or (in the case of a dentist) their new office building!!

I know it's fashionable to trash MAPD plans (vs. supplements, for example), but in my (admittedly) limited experience as an agent (8 years), the problems my clients (including my own father) deal with re: claims are overwhelmingly due to errors or shady activity on the part of providers, not the carriers. No wonder providers/hospital groups lobby so hard against MA.

 

[Rossat]

From my own personal experience (not in Medicare) I have questioned, and was reimbursed, over 12 dental claims over the past 3 years and the provider made a “mistake” on every single one.

The problem is most don’t question their doctor and that’s just profit for them.

 

[DonP]

Here's the situation: my father is on an MAPD plan with dental coverage. I also represent the carrier he's with. So back on March 8 he needed to have two teeth extracted. I found a network provider in our local area to do the extractions. On the day of service, they charged us $264. I objected, stating that as a network provider they should handle all claims and there should be no co-pays on these extractions. They insisted that it was a formality and that they would reimburse us as soon as the claim was paid, so I paid the $264.

A couple of weeks go by and I don't hear anything. I reach out to the provider and they say they haven't been paid by the carrier yet. I wait a few more weeks and still nothing. Today I reach out to the carrier, who informs me that a check was mailed out to the provider on 4/11. So we're now 18 days past the date the check was cut, and I've heard nothing from the provider. I call the provider, who tells me that refunds are issued every Friday and that ours will be issued this coming Friday (without explaining why three Fridays have already passed without the refund being issued).

Here is my suspicion: I wonder if the provider is charging all network patients a similar upfront charge, and only refunding those savvy enough to expect it. I can't prove it (yet) but I want to make sure my clients aren't being taken advantage of by bad actors.

I saw this note and I’ve had 2 calls in the past week on mapd dental benefits . These in network dentists are charging the patients up front and saying either we’ll file the claim or you file the claim . I didn’t know an in network dentist could charge up front if all charges are paid by your in network plan ? What’s happening is these dentists are charging for tons of “ extra’s” not covered by the plan . I’ve also had the experience these dentists are stalling patients in paying them back well after they got paid by ins company .These in network dentists are gaming the system . There using these mapd patients like cattle at the slaughter . Members with plans that cover 100% are always paying “ extra”

 

[Yagents]

It seems the shiny bells and whistles of mapd.....ain't so shiny

 

[Limozine]

It seems the shiny bells and whistles of mapd.....ain't so shiny

In nearly every single case in my experience, it's the providers, not the plans/carriers, who are abusing the system. MAPD isn't the problem; providers who agree to one thing and then use questionable, unethical, or illegal means to circumvent the agreement are the problem.

 

[ICACharleston]

What would you do?

Isn't that covered in your recerts for Waste, Fraud and Abuse? Nobody wants to bang heads with their regular dentist but it sounds like a one time deal with this dentist.

I recently recovered a charge from my wife's dentist, who apologized when I pointed out the error but I'm sure she didn't go through her books looking for similar overcharges.

 

[somarco]

How often do you, the agent, see attempts at 2x billing by providers? Is it the same ones, time after time? Does this occur mostly with dental coverage or are other lines involved?

How often does this happen and your clients never say anything, they just assume they owe the money and pay the bill?

When I was active in the individual and EGH market it was not unusual to discover my clients were paying the bill without question, on the assumption the carrier was right to deny/short-change the reimbursement, and move on.

I coached them to ALWAYS ask me before paying a bill where they owed more than the carrier paid. This led to a number of calls and emails I would not otherwise get, but at the same time, the claim was properly adjudicated and paid.

There are probably times where the provider was wrong, but it didn't happen often enough to storm the castle.

Almost every time, the problem was my client did not understand how their plan worked and I would go over it again.