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

[Midlevel]

My daughter is in her 11th year of the process of becoming a Dr. and has 1 year of residency left. I asked her and two residence Drs who just finished and are onto their 1st job how much they learned or discussed Medical insurance. They all said not once has it been brought up. But yet all these Drs and nurses telling everyone to stay away from MAPD’s, there is one reason and that is for their own benefit and so their staff doesn’t keep bitching about how hard it is for them to bill someone other then OM or actually have to get PA like it should be.

My clients have figured out to worry about their own pocket books and which plans are best for their situation and not some Dr trying to pad their pockets with every test available to mankind. And yes, I will be telling this story a few times this AEP. They should stay in their lane, I don’t go around changing someone’s prescription or diagnosing them with a medical condition.

 

[rmhaire]

there is one reason and that is for their own benefit and so their staff doesn’t keep bitching about how hard it is for them to bill someone other then OM or actually have to get PA like it should be.

It's not so much the billing that's hard. It's the getting paid that's hard.

 

[adjusterjack]

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.

It's quite possible. I have found that many of the new dentists cropping up in Phoenix over the last couple of decades are scammers because they financed a franchise that provided them with a fully equipped modern office that they have to pay for. They rely on a patient's fear and lack of knowledge and end up doing thousands of dollars worth of unnecessary work. And they finagle the insurance, too.

I'm sure similar scams exist elsewhere.

 

[Midlevel]

It's not so much the billing that's hard. It's the getting paid that's hard.

Not sure my clients care if it takes the Dr making 400000.00 an extra week to get his bag. I know I sure don’t care.