Mom is 92 with dementia and is in memory care unit of an AL facility. I was alarmed to see on her EOB from her secondary insurance a $960+ charge from a lab. Seven tests all listed on 2/19/2021. I received the EOB in October. Insurance declined to pay (with the note that she may receive a bill). A couple months later I saw another EOB where the same lab resubmitted the charges reduced to $500+ for the same date. Insurance paid.
Now in December two more EOB's show charges of $125 and $1,000+ - all still for the same date! Surely this has to be blatant fraud!! But WHO do I talk to about this?
(I went to the director of the facility who said it was charges for testing - and they tested not only for covid, but for any and everything that might be on the test swab. It is ALL important to me that I do not have trouble that forces me to move Mom. But this can't be right. I just don't know who I can go to with this).
Download the Medicare booklet and read it to understand. You can also go online to see what the claims are and what Medicare has approved.
https://www.medicare.gov/media/10991
You can also ask for a copy of all test results which will verify that they were actually done. The date of the blood draw will be on the test. You can also sign up at Quest and/or LabCorp and be able to see test results there.
Itemized
I have reg Medicare and my husbands Union provides my supplimental. The supplimental only allows the use of LabCorp for labs. I have to make providers aware of this. Have even been told that Medicare will except and pay for any Lab. True, but my suppliment will not pick up the 20% if not LabCorp.
Believe me, you can't really do anything until they actually bill you. Its not fraud till they bill you. Statements can be wrong and they can be adjusted. They can charge anything they want to, if they except Medicare they also except what Medicare thinks is reasonable. I still think the Lab is trying to correct a billing error on their part by constantly by re-submitting the original claim. It comes down to the Lab has a lousy medical billing clerk who is coding that lab wrong and Medicare is not excepting it. As I said Medicare pays very little towards labs, very little. And you cannot be billed for more than Medicare considers reasonable.
Just wait for the bill. Don't call anyone until you receive it. If it still seems unreasonable, then look at the Medicare statement and the secondary statement to see how they paid. Again, a secondary only pays the 20% of what Medicare has paid. If Medicare has turned down the claim, so will the secondary.
The one problem I have with Medicare is they send out a statement for each service provider they have paid. Then they send out a Summary listing again All the services u had done within a certain time frame. Like a duplicate. For me this is really confusing because when I get a bill I don't pay it until I get the statement from Medicare and my secondary. If the bill totals what Medicare and my secondary say, I pay it and throw out the statements. I don't need any summary.
In 2008 I had spinal fusion surgery on my neck; I was in the hospital for 24 hours. The bill was $249,000.00. I was flabbergasted and immediately felt like the bill was fraudulent. I called my insurance company who was United Healthcare at the time. The representative laughed when I expressed my concern at the exorbitant bill. She told me not to worry, that ridiculously high bills were part of the game the hospitals played with the insurance companies! I was irritated, to say the least, thinking I was doing a good thing, only to be laughed at.
My mother has lived in MC Assisted Living since June of 2019 and has had lots of lab testing over the years, including mobile lab testing where the company comes into the MC with their equipment (which is extra costly). Never have we paid more than our contracted co-pay for any of the services in all this time.
If I were you, I would not spend hours on the phone calling Medicare and trying to prove you're the POA and all that jazz. Just wait to see if you get some outrageous bill FIRST before you freak out. If not, just let the lab and the insurance companies duke it out; it's between THEM, really, you know?
This is how it works. The lab bills Medicare lets say $1000. Medicare approves $600 (lab has to except this if a Medicare lab), Medicare pays 80%, $480. That leaves a balance of $120 which Medicare sends onto the suppliment of record who then pays all or part of the $120, depends on the contract Mom has with supplimental. If Medicare turns down the charge, so will the supplimental. If Mom has A&B her labs are covered.
Again, there is probably a coding problem. This is the Labs problem to fix. Now, when it comes to Medicare and lab work, Medicare pays the Lab hardly anything. You need to wait for the billing from the Lab to get this straightened out. That billing should show what Medicare paid and what the suppliment paid. Like I said, not all suppliments pay the 20% Medicare does not pay. With mine, we are on a share plan and you have deductibles that have to be met.
If the billing seems outrageous, then u call Medicare. A provider who can bill Medicare has to except what Medicare pays. With my example its the $600. Medicare paid 480 leaving a bal of $120. If the supplimental does not cover that $120, let say it went toward Moms deductable, then Mom owes that $120.
I would ask that no labs be done on Mom without consulting you first, especially if you have POA. There are rapid COVID tests that can be done and more accurate PCR. Under government guidelines, these should be free of charge. They should not be doing these tests at random. Mom needs to have been exposed and I think showing signs. Your local health dept can tell you. IMO the director has no idea what he is talking about. If its a COVID test that is all that the lab should be testing for. My daughter just got her statement and the charge for COVID testing was $600 by the lab but her insurance paid it. There will always be a charge by the provider, but between Medicare and secondary insurance it should be covered.
She said that company has a policy that they "absorb the charges" if the patient is billed.
Sounds really fishy to me - and especially now that I see they are still billing more and more charges for the same day.
A couple of years ago there was a scandal about one of the major labs. They were billing routine tests, like a CBC, as individual tests; Red blood cells. White blood cells, liver function, kidney function, etc. So instead of one charge to the insurance company for, say $75, they were billing each component out at $75.
About the "double billing"-sometimes this happens when one billing period ends and the next one begins and perhaps who ever entered the information about the labs didn't click on the next tab to start the next billing cycle. When this happens to me, I'll call them and ask if it's ok to wait a few weeks until the cycle sorts itsself out-never had a problem doing that.
Do you have power of Attorney? Makes a huge difference in stuff like this. As well as an elder specialist lawyer too, just to make sure you're doing the right things legally in your state.
In a brief search I couldn't find any governing body to report it to. One of my sons works in a lab at the Mayo and I have asked him if there is any accountability for labs. He says, "The College of American Pathologists provides oversight and accreditation." That's where you should start, I'm guessing. Even if they're not the ultimate leverage they probably will point you to the right organization or pathway for action.
Personally, I'd just love to see the legal community go after them with class action suits for misrepresentation of drugs' values, curing possibilities, as well as contributing to an epidemic of drug use.