Insurance fraud: any of my business?

After a mini-stroke at the end of May, I’ve been going to physical therapy and (slowly but surely) recovering the use of my left limbs. About 10 days ago, the first bill from the PT center arrived, and several mysteriously named items were shown as not covered by my insurance (BCBS of Illinois). When I asked one of the employees about those items today, he pointed to some equipment I’ve never used in a room I’ve never entered. He said he thinks the owner just bills every patient for pretty much every piece of treatment equipment in the clinic. I’ve never signed anything at this clinic, or agreed to any specific treatments in something like a written treatment plan. I just show up and the employees tell me to walk on the treadmill for six minutes, or use this hand weight or that weight machine, or whatever.

I’d like to finish out my therapy at this conveniently located place, where I feel I’ve gotten pretty good advice and treatment, but I’m not sure just what to do about what seems to be insurance fraud. The employee to whom I quietly showed the bill today said that when another patient, a lawyer, once made similar inquiries, the clinic owner first said he’d talk with the (nonexistent) “billing department,” and then told her not to worry about those charges. The employee also said he’d once accidentally seen the annual revenues for this location, only open 30 hours a week with three staffers, it was “a couple million dollars.”


Somewhat confused here. When you say the items were on your bill, I presume you mean they were charges on your bill. And when you say that the charges are showing p on the bill as not covered by your insurance, I get the idea that they’re trying to charge you for the use of the items.

Let me know if my chain of reasoning is faulty, but on the face of it, it looks like you are the one they’re attempting to defraud. If so, then yeah, that’s your business.

I’m sure you have better ethics than this.

I certainly think you should check to see if your insurance company was actually billed for these things and if they were you should notify them that you didn’t use them, whether or not the insurance paid for them.

I also wanted to say sorry about your mini-stroke and hope you are making a full recovery. And if I were in your shoes I’d keep going to this place for my PT and keep a close eye on future bills. After all, the therapists aren’t (presumably) the ones doing (presumably) fraudulent billing.

Bring it to someone’s attention, at your insurance company, in writing, only AFTER you’ve completed your therapy. In the mean time, document your actual machine usages for your remaining visits.

Write it up as a nice polite letter and send it snail mail, registered. Make it clear you don’t suppose to understand the inner workings of such things, but felt you needed to share, and have a lovely day!

Then let it go. You became curious, made inquiries, received confusing info, logged your machine usage, from then on, wrote it up and sent it to insurance company. Seems like you’d have done everything you could and the onus is now on them, to my mind.

Well it’s not insurance fraud, if the insurance company isn’t covering or paying for it. It sounds like improper billing. Is the PT place expecting you to pay for the services since BCBS isn’t paying for it? If so, take the owner to task for billing you for services that were never rendered. Then report them to the “Better Business Bureau”, the local prosecutor, and your local news (paper and television); if you’re willing to go that far.


You should ask the billing office at the therapist about it. And just say you’re confused about what seems to be an error in your bill. See what they do. They might be charging everyone like that and assuming, probably correctly, that most people aren’t as perceptive as yourself. They might correct your bill without second thought.

Then, after your therapy, you might contact your insurance about the potential fraud going on.

That’s probably what I would do.

My wife is a PT and left a practice because the owner insisted on billing for services not performed. They do it to max out the insurance payment. If you ask, they’ll probably “forgive” the charges - IOW, they want to gouge the insurance company, not you. Independant confirmation that this has happened before speaks against it being a mistake. The right thing to do, IMHO, is to stop going there immediately (if they will cheat on the bill they WILL cheat on your care), immediately report the therapist to the state licensing bureau and the insurance company.

Frauds need to be run out of business. Any business.

The way he wrote it, it seemed like he only cared if the person has to pay out of pocket, he didn’t care if the insurance company was being defrauded.

Fraud is fraud, and that company needs to be reported.

Chances are that a practice that small uses a third party billing company. The diagnosis and prescriptive treatment would likely determine what you and your insurance are billed regardless of what you actually use.

Just an educated WAG.

Improper billing is insurance fraud.

It is an attempt to defraud the insurance company. It most assuredly is insurance fraud. Just because the insurance co didn’t pay doesn’t make it any less fraudulent. For that matter there could well be charges that are fraudulent that BCBS did pay.
Report them to BCBS AND your state’s insurance commissioner.
This shit cost all of us money in higher premiums.

Yep. Yours and everybody’s business.

Sorry, l was apparently unclear. To my understanding, the insurance company was explicitly not being billed, so there could be no question about insurance fraud. But it looks like the OP was being billed for services he did not receive. That is why I asked for more information.

:smack: Wait, is this some type of scheme to cause the patient to appear to have met his deductible without having actually spent some money? If so, yes of course that should be reported.

It certainly is your business.

If you or your insurance company are being charged for things you never used – which is what submitting a bill for services not rendered is – it is insurance fraud. This raises everyone’s costs!

Call the insurance company and point those items out on your bill. If the CSR is dense (and some of them are), point out that yeah, the insurance company didn’t pay, but the PT office TRIED TO BILL FOR SERVICES NOT PROVIDED. Which is blatant, outright fraud.

Let their fraud team investigate.

Don’t mention this to the PT staff.

If they try to bill you, point out that those are non-covered and you don’t have to pay based on the contract with your insurance company.

source: 20+ years working in health insurance. A little of it in an anti-fraud unit.

It’s still fraud. Even if a provider uses a billing company, the provider is accountable for the claims submitted, and should be telling the billing company what services were provided.

This kind of stuff get providers visits from the anti-fraud units. God help them if they bill Medicare this way; they don’t play games.

Don’t call it in, write it out and send it snail mail, registered. That way it can’t be swept under the carpet as there is a paper trail AND a signature that it WAS received. Greatly increases chances of it not just being ignored.

Amen. :frowning: :mad: