Doctors tussle with insurers — and sometimes patients lose, too
Sometimes, the amount in question is less than
"You feel like you're being slapped on both cheeks," she said.
Most patients aren't aware of this behind-the-scenes tussle, but they might feel the effects -- beyond encountering a frustrated doctor distracted by billing queries.
Some patients might discover their doctors no longer accept coverage from their insurance carrier, and more doctors have stopped taking insurance altogether -- roughly 10 percent in
In most cases, doctors can't legally ask patients to share the cost.
Virtually all of the insurance companies and government-sponsored coverage programs in
Doctors have contracts with insurers that detail what is covered and how much reimbursement is owed. But sometimes after the insurance company pays the doctor, it goes back and reviews the claim. The demands for recoupment can come months later, long after the doctor's office has closed the transaction. The doctors can dig back through the records to appeal, but many don't consider it worth the staff time. For Poonawala, the nickel-and-diming added up to real dollars, and many refund demands came more than a year later, she said.
"It's just greed," she said.
"Absolutely not," said
Some of the errors stem from physicians using the wrong billing code, she said. When doctors use paper, rather than electronic claims, error rates rise, Krusing said.
"Overpayments shouldn't happen in the first place," she added. "There needs to be a system where the accuracy of payments is a streamlined process."
Recoupment -- which can occur for many reasons, including billing a higher amount or billing the wrong carrier when a patient has additional coverage -- is among the top five complaints the
The TMA has helped some doctors with payback demands, and it's not unusual for the insurers to back off, Davis said.
"I would say I hear from hundreds of physicians a year about this, if not thousands," she said. "I think it's one of those things patients don't realize is even going on."
Unless they lose their doctor.
Recoupment is one reason Dr.
He practiced with a group in
"They said, 'there's a checklist you didn't document,'" Crump said. "A lot of it is just nonsense, in my opinion."
As a no-insurance provider, building a patient base takes time, he said. "It's a trade-off. You get paid more if you take insurance, but the flip side is you have to follow all their rules and play their game."
Many doctors simply pony up when hit with a payback demand.
In the last six months, Poonawala said
"If it's too high, then pay less. ... We've already done the service," he said. "It's
If the doctor doesn't pay up in a month, penalties and interest start, documents show.
Calling the company to ask questions is generally an exercise in futility, the Poonawalas said. At one point,
Just a year ago,
Doctors who study their health plan contracts can sometimes avoid being surprised by overpayment demands, experts said.
"Our contracts with the care providers participating in our network specify the rates that should be charged for various services, and if a payment exceeds the contracted rates we may follow up with the care provider to ensure the appropriate balance is collected," UnitedHealthcare spokeswoman
One reason the recoupment practice is escalating is that insurance companies have seen the government's
Even so, she said, in at least half of the cases she knows about, commercial insurers miscalculated. She cited two cases in which doctors protested recoupments exceeding
"They're banking on you not responding," Rodriguez said. "A lot of times it's nitpicky things, and they (doctors) just need to do a corrected claim."
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