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Old 08-08-2017, 09:35 PM
 
19 posts, read 35,583 times
Reputation: 12

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Hi All,

My OB's office (in-network) refused to bill my insurance for the prenatal visits I had with them so far (about 3-4 visits). They insisted on me paying out of pocket and claimed that it's because my insurance doesn't cover prenatal care visit. This is not true. I have verified my insurance does cover prenatal visits at 100% without member cost sharing IF the provider bill these as prenatal visit (meaning using pregnancy related codes). So these routine pregnancy visits should have been covered.

I could not think of any reason why they say my insurance won't cover the prenatal visits other than:

1) they intend to bill my prenatal visits as non-pregnancy related;

2) they lied...

What should I do now?

Thanks!!!
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Old 08-09-2017, 06:55 PM
 
1,158 posts, read 948,665 times
Reputation: 3279
You need to contact your insurance company and find out if the carrier has a Special Investigations or Fraud Dept and report the provider.

If the provider is in network with your insurance carrier it is a violation of their preferred provider agreement.

The provider does not sound reputable.
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Old 08-10-2017, 03:11 PM
 
11,181 posts, read 10,470,006 times
Reputation: 18618
It sounds like your OB might be doing "global billing", a common practice. You can google the term.
Too complex to go into here, it basically means your prenatal/delivery/postpartum charges are all rolled into one "global" charge and the insurance won't pay until postpartum but the OB needs/wants prenatal charges paid now, not 6-8 months from now. So they're asking you to prepay although to them it's really not prepay, it's current pay for current services rendered. You'll get reimbursed when it's all settled after delivery and postpartum.

At least that's my understanding; like I said it's a common practice. The best way to find out what's happening is to sit down with the billing person in the doc's office, have them call the insurance co. with you there, and have them both explain it to you.

Health insurance is so complicated, good luck.
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Old 08-10-2017, 04:05 PM
 
9,720 posts, read 7,543,347 times
Reputation: 24122
My daughter in law had trouble with her OB as well. First they told her she didn't have insurance, which she did. Then they told her they said that because her plan had such a high deductible. She has to pay $450 every visit.
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Old 08-11-2017, 02:18 AM
 
1,158 posts, read 948,665 times
Reputation: 3279
It does not sound to me based on the info that you have given that your OB is doing global billing. They advised your insurance does not cover prenatal visits which is not true. Preferred providers are only able to bill you in advance for deductibles and coinsurance, not the full cost of your visit.
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Old 08-11-2017, 11:08 PM
 
6,034 posts, read 4,387,021 times
Reputation: 13531
You can usually contact the insurance and send them copies of any bill you receive for covered services and let them sort it out with the doctor.
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Old 08-11-2017, 11:36 PM
 
Location: Minnesota
2,594 posts, read 2,145,634 times
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I work for Prudential in medical claims many years ago. When the insurance pays OB/prenatal they figure that as one charge (pre-natal and delivery) and bundle the charges together to get total which they look at as one charge, they of course pay at what is usual and customary for that type of service in your area. What the Doctor office is trying to do is "un-bundle" those charge to charge separately, not as a unit, to be paid at a possible higher amount. If they bill as something other than a pre-natal visit, and that's what it is, they are not subject to the bundling of the pre-natal cost containment. That is frowned upon and probably is against the contract the doctor office has with the insurance as a in network doctor . and possibly fraud.

Doctors offices do what you to pay the deductible amount you will owe, usually by the mid point of your pregnancy, that's common.

I saw similar thing when blood test are done. Insurance bundles certain tests together for a panel of test, the costs are less for lab and doctors too. Occasionally we would get each test billed separately to get paid at a higher rate. If they were truly only testing for one thing that was OK panels not OK.... and the doctors office know this.

I would look for another OB who is not trying to possibly scam the system.

Last edited by Izzie1213; 08-11-2017 at 11:48 PM..
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Old 08-13-2017, 01:07 AM
 
Location: Minnesota
2,594 posts, read 2,145,634 times
Reputation: 4977
Also, FYI

On occasion when insurance suspects fraud in billing practices they may suspend paying doctor and ask for the copies of your medical chart to confirm the billing codes to the what services where actually done. If they falsify your charts to go with what they are billing for they could be in a world of hurt. I had been involved with requesting records. You may have already signed a release for insurance to get medical records but if you see insurance requesting a release from you again that may be what is going on.
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Old 08-22-2017, 09:45 PM
 
Location: CA--> NEK VT--> Pitt Co, NC
385 posts, read 435,970 times
Reputation: 426
Quote:
Originally Posted by Angie682 View Post
You need to contact your insurance company and find out if the carrier has a Special Investigations or Fraud Dept and report the provider.

If the provider is in network with your insurance carrier it is a violation of their preferred provider agreement.

The provider does not sound reputable.
This.

A participating provider is a clinician who is contracted with your carrier to provide services and accept certain requirements for both billing and payment.

Assuming they are participating (and usually that means in-network too, but not always), they can only collect the copay up front. All other monies collected from you are on a post-adjudication basis, meaning they must submit a claim first and receive a remittance or explanation of benefits BEFORE billing you. That remittance is a legal financial document declaring a debt. They cannot collect money from you without that legal document first per various credit laws that protect you from anyone claiming you owe them money (like the Fair Credit Reporting Act). The law forces them to have proof of a debt and this is how that debt is declared. ALL insurance company contracts with providers conform to the existing credit laws so it doesn't matter which company you get your insurance from, if the doctor is contracted, s/he cannot bill you for deductibles or coinsurance prior to claims adjudication. They would have no idea of the exact amount to bill you for...and they are not allowed to guess.

As for the prenatal visits, all OBs are paid via a global fee. There are very few reasons a doctor can submit a claim for prenatal visits as they happen (or bill you up front for them), like if you change doctors at any point in your care after being diagnosed pregnant (there's some small wiggle room at the very beginning there, but not much), insurance policies that exclude maternity benefits (which shouldn't happen anymore, but I'll mention it any way because this definitely used to happen) or policies that pay a flat amount no matter what charges are incurred.

The OP didn't say she changed docs so I am going to assume that she didn't. The only claim insurance companies really want to see is the delivery. That confirms the end of prenatal care, starts the clock on post natal care, and confirms the end of the pregnancy, at which point the insurance company "happily" pays the global fee minus whatever financial debt you owe (deductible and/or coinsurance). Unless she is an exception, what this office is doing sounds shady.

If the OP did not change docs, I would call the insurance company and advise them that a participating provider is billing for services that have not been submitted for claims processing. If you get a novice, ask for a supervisor. All customer service reps should know what this means, but you do get the dumb and the new so be sure to press until someone understands. What they should do is take the name of the doctor and some details on your issue and pretty much tell you to not worry about it; they will take care of it. Someone from the carrier's provider relations department will contact the provider and give a friendly reminder of the constraints of their contract. If you still get hassled, call back your insurance company and complain that the requests for payment before claims submission have not stopped and you want them to investigate fraud. It is fraud from the beginning, but you have to let them give the doc a warning. Usually once you get to talking about fraud, the carriers sit up and take notice.

In the meantime, remind the doctors office that they participate with your insurance company and they are not allowed to bill for prenatal care or for deductibles/coinsurances. I usually say that I would be happy to do a joint phone call to the insurance carrier with the provider or office manager to confirm. I have yet to have anyone take me up on the offer. Stay nice though unless your plan is to change docs. You don't want to develop an adversarial relationship with a doctor. If it gets tense like that, change practices. Don't leave your care in the hands of someone with a grudge. The vast majority though go on treating you professionally and there shouldn't be an issue.

FTR...I processed BCBS and Medicare claims for 5 years, and have worked in doctor's offices (including OBs) and hospitals for much of the last 28 years submitting claims and following our carrier contracts rules/requirements. None of this is new. This is how the industry has always worked.
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Old 08-26-2017, 01:37 PM
 
1,652 posts, read 2,756,958 times
Reputation: 2640
Are you guys saying the OB has to wait 9 months to get paid for the initial pre-natal care? What if the patient changes doctors at the end and another OB delivers the baby? Maybe I'm confused.
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