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The medical billing process in the United States is complex for both doctors and their patients. Medical procedures are never cheap, and the cost of a doctor or hospital visit may surprise many patients. However, unethical medical professionals may also try to get extra money out of patients. For example, doctors may bill patients for procedures or tests that the patient never received. If you believe that you have been fraudulently billed, first try to sort the bill out with the doctor or hospital. It may have been an honest mistake. If they refuse to correct the charges, contact your health insurance provider.
Steps
Working with the Doctor or Hospital
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1Contact the hospital's billing department. In case the doctor or hospital made an honest mistake, it's best to bring the billing error to their attention as soon as you notice the problem. Look on the office's or hospital's website to find information regarding billing disputes.
- If the billing department doesn't have contact information listed, call the office's main number and ask to talk to someone in charge of billing disputes.
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2Request the CFO's contact information. If the hospital billing department doesn't correct the billing error, request to contact the Chief Financial Officer. Explain your concern with the billing to the CFO, and ask them what they can do to rectify the situation.
- In some cases, the threat of contacting the CFO will be enough to make the billing department take your claim more seriously.
- If you're dealing with a small office or individual practice, there may not be a CFO. If this is the case, you can request the contact information of the head doctor.
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3Work with a medical billing advocate to rectify the fraud. The advocate will be able to determine whether you have been fraudulently billed and, if you have, they'll follow up with the hospital or with the state medical board.[1] If you're not comfortable accusing the hospital of billing fraud, or if you simply don't have time to pursue the issue, a medical billing advocate may be your best option.
Reporting Fraudulent Billing
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1Contact your state's Department of Health. If you're confident that you have been fraudulently billed, and the hospital or doctor refuses to alter the bill, the next step is to contact the state DOH. Many states will have a medical board within the DOH that evaluates claims of unethical medical conduct or fraudulent billing. This board will investigate the billing fraud on your behalf.[2]
- If you do not live in the United States, contact the government medical board that governs the region in which you live.
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2Report the fraudulent billing to your insurance company. In almost all circumstances, your insurance company will be paying for the majority of your medical bill, so they'll be very interested to hear about suspected fraud. Your insurance company will contact the doctor or hospital and inquire about the suspicions medical procedures or tests you've been billed for.[3]
- The National Health Care Anti-Fraud Association (NHCAA) lists contact information for major insurance providers online at: https://www.nhcaa.org/resources/health-care-anti-fraud-resources/private-health-care-fraud-contacts.aspx.
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3Report insurance company fraud to the State Insurance Fraud Bureau. In extremely rare cases, your insurance company may be participating in the fraudulent billing with the unethical hospital or doctor's office. In this case, you need to report the fraud to your state's Insurance Fraud Bureau.
- These Bureaus are typically run through the state Department of Insurance or Attorney General's office.
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4Call to report fraudulent billing by a health-care provider under ACA. If you're registered for your health care under the Affordable Care Act, you can contact their billing department directly. Report the fraudulent billing you've experienced, including the name of the medical facility, the supplies, operations, or tests you were incorrectly charged for, and the amount of the charge.
- Contact ACA Billing at 1-800-318-2596.
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5Contact Medicare in the case of suspected billing fraud. If you receive insurance through Medicare, you can contact them directly in the case of billing fraud.
- Various Federal laws have been passed to protect Medicare clients from being falsely billed and to prevent doctors from sending falsified bills to insurance providers.[4]
- Call Medicare to report billing fraud at 1-800-632-4327.
References
About This Article
Medical billing is a complex process for doctors and patients, but if you believe that you’ve been fraudulently billed, then you’ll want to sort it out with the doctor or contact your health insurance provider. It’s best to bring the billing error to the doctor’s office’s attention first in case it was an honest mistake. If the billing department can’t help you, then ask to contact the Chief Financial Officer. You can also try working with a medical billing advocate to fix the situation. To find an advocate in your state, visit the website billadvocates.com. In cases where you need to report fraud, contact your state’s Department of Health. You can also contact your insurance company since they pay the majority of your medical bills and will want the situation fixed. In the rare case that you suspect your insurance company has participated in the fraudulent billing, then contact your state’s Insurance Fraud Bureau. To learn how to report fraudulent filing by a health-care provider under the Affordable Care Act, keep reading!
