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.