Question
Doctor over charging insurance company?
I am so mad ! I went to an orthopedic doctor cause my back went severely out and I could not get out of bed for 4 days. I called ahead to see if the doctor was covered on my health insurance. The receiptionist called back and said yes. What I did not know was that yes I am covered but not under the health insurance network (which would have cost $40.00 out of my pocket) So I went into his office and got xrays from the radiologist in the same building and then saw the doctor. He barley looked at my xrays, talked to me for about 5 minutes and reccomended physical therepy. I told him I want to get to the source of it so I don't have to have surgury in 5-10 years but he offered no real solution. I felt ripped off. The next day I went to a friend reccomended doctor who spent about 20 minutes with me and wanted an MRI done as he felt there was a slipped disk problem. My problem is that the first doctor billed my insurance $450.00 and did nothing really and I have to pay most of that. THe code he billed is 99245. When I called my insurance co to complain they said the doctor can bill whatever he wants !! What can I do to get my bill lowered? The insurance co just took a complaint over the phone and suggested I get in contact with the doctors office to see if they can bill for less, seems unlikely though? I feel I was lured in there by their receptionist into thinking I was in their network for my insurance company and then totally raped on the fee. If anyone knows a workable way to get this bill reduced that would be great. I don't really want to send complaints about the doctor to anyone and get him in trouble. Switching doctors was my solution for that. This is the first time in years I have used my insurance for anything and this is what happened ! Anyone know how I can get this money out of pocket lowered?
1 month ago - 5 answers
Best Answer
Chosen by Asker
The code 99245 is a standard code for specialty physicians to use for a new patient visit. I think you are saying that the doctor you saw was not in network with your insurance and that when you made the appointment the receptionist told you differently. You should call the office and speak to the office manager and explain the situation. Let her know that you realize you have to pay the bill, but because of what the receptionist told you when you made the appointment you had no idea you would be paying the entire bill. Ask her if there is anyway they could make an adjustment to your bill. I can only tell you that before you see another doctor call your insurance company ahead of time to make sure they a participating physician and then double check with the doctors office too. In reality doctors cannot charge whatever they feel like, they do have to have medical documentation to back up what services were rendered at the time they saw you.
Source(s)
18 years of work experience in medical office.
by goldengirl
1 month ago
Asker's Rating: 
Other Answers
Its your fault for not finding out what the doctor charges. They can charge whatever they want and you accepted the services. You are obligated to pay. Doctors usually charge the insurance companies more. If you let them know that you are paying out of pocket the rate is reduced.
by bob- 1 month ago
call the insurance commissioner in your state and the local physicians licensing board and the consumer protection agency and state attorney general...
by THE TIME IS NOW- 1 month ago
emuniversity ... Link explaining code 99245. Anytime you see a specialist the 1st time they can use since they have to get your health history, consult with you and make recommendations. Do you have your EOB (explanation of benefits) from your insurance company? It should show if this doctor is in network or out of network. It will also show amount allowed. This is the amount the insurance company believes is the correct rate to charge for this service. I suspect he is out of network and charges more. So if in network, the contracted rate with your insurance company could be $250 to $300. (amount allowed) If he is out of network and since you called the office to confirm covered by your insurance company, see if you can get them to negotiate the amount owed to the in network rate. If not, you can complain to the state board of doctors of this charge. At that point he will have to document his service. One of the biggest problems for doctors out there is that they are required to see too many patients today and the average time allowed per patient is around 15 minutes. On any new consult, they have to spend more time getting your medical history, RX etc. On subsequent visits, they use a different code that they charge less since they already have the basic info and is follow up. Thankfully you got a new doctor who appears to satisfy you in his plan of treatment. But in the future which you just learned, you ALWAYS need to call your insurance company 1st and verify if the doctor is on the plan or not. One other option would be to call several other orthopedics and ask what a new consult would be with them. You may find that most charge only $350, so this doctor is charging much more than the average. good luck
by lucy- 1 month ago
Lesson learned - you need to call YOUR INSURANCE COMPANY to verify exactly what is covered how. it's not up to the doctor, it's up to YOU. You are fully responsible for the out of network charges. You're not going to be able get this lowered, sorry.
by mbrcatz- 1 month ago