Money, “Yelp!” and health insurance fraud- Musings of an NYC dermatologist

Sometimes online review sites reflect more about the reviewer than the business...
Sometimes online review sites reflect more about the reviewer than the business…

After many years of practice, I am finding that money makes people “Yelp,” while the real issue is health insurance fraud.

Money-related matters seem to be the biggest irritant for health care consumers these days.  Are you surprised?  Times are hard.  Notwithstanding, manifestations of the irritation seem to be finding their way, more and more, to review sites.  Not uncommonly, patients who initially expressed satisfaction with their care and experience, become dissatisfied because they received a bill for a service that they did not understand was their responsibility to pay for.

Health and money are very emotional topics.  As a result,  the topic of payment for health services can be a touchy subject.   Many times  it is a patient’s issues and confusion around money matters that drives a patient who initially expresses satisfaction with the results to later communicate dissatisfaction after they receive a bill.  This, at times, sets the person off on a destructive course of action, such as posting negative reviews on the increasingly popular doctor review websites which may support and promote unhelpful triangular communication. At the risk of being perceived as having “sour grapes” about some bad Yelp reviews (such as the one copied below) I think it is more important for me to share what I do know as a medical professional in order to empower patients.  Review sites may not be your best resource for getting you questions answered.

In these challenging economic times, even patients with insurance, ironically, are being confronted with notably higher out-of-pocket costs.  Although the amount of money paid to physicians is declining or staying the same, patients with health insurance may find that they owe more and more money towards a deductible, coinsurance, or copayments (copay).  Stuck in the middle, the doctors now have the additional obligation, and expense, of being bill collectors which can have a negative impact on the doctor-patient relationship.  And we wonder why there is a trend of doctors choosing not to participate in health insurance plans.

Many people do not know that insurance is a legally-binding contract between three parties:  the insurance company, the doctor, AND the patient.  All parties have obligations.  Doctors who participate in insurance plans agree to provide services at an agreed upon discounted rate.  Insurance companies agree to pay for covered services in a timely fashion.  Patients are also legally obligated to follow the terms of their contracts such as getting referrals, seeing in-network doctors, and meeting the part of the financial obligation called “patient responsibility.”

When a doctor participates in an insurance plan, regardless of what the amount he or she bills, he or she is only entitled to receive the agreed upon amount of money—usually a discounted amount.  Why would the doctor give discounts to the insurance company?  The benefit is to have access to patients who participate in the insurance plan.  The downside is that payment is discounted and not made at the time of service (sometimes weeks to months later) and billing insurance companies and patients adds to health care costs.

So, who pays what?   This is determined by how an insurance policy is structured.  Below is an example of how it may work:

Let us assume the amount of payment the doctor is entitled to receive under the terms of the contract to which the doctor has subscribed is $100:

if there is a deductible of more than $100 then the insurance owes $ 0.00 and the patient owes  $100.
if there is a copay of $50 the insurance owes $50  AND the patient owes $50.
if there is coinsurance at a rate of 20%  the insurance owes $80 and the patient owes $20.

Some plans are structured such that there may even be a combination of deductible, copayment, and coinsurance.

When a doctor bills an insurance company but fails to collect, or at least attempted to collect, the monies owed by the patient, he or she is committing insurance fraud which can result in fines and penalties including imprisonment.  Further, patients who fail to pay their deductibles, coinsurance, or copayments are also in violation of their insurance agreement and could potentially lose their health coverage.  It’s simply the law. Unfortunately, uninformed patients attempt to use forums such as Yelp to intimidate doctors into committing health insurance fraud.

Armed with the above information when you read the below review, copied from Yelp,  do you think that this anonymous reviewer knew what his/her obligations were according to the terms of his/her insurance contract?  (hint: “I was charged…”).

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1 review

J. A.

The WORST dermatologist I’ve ever encountered. Everything people have said about her poor bedside manner is absolutely true and her office staff is even worse. I waited over 45 minutes for my appointment which only lasted 10 minutes although I could tell the Dr. was hoping it would be more like 5.

She was also physically rough in handling my skin and let out an exasperated sigh when I expressed my discomfort.

She did not take the time to explain what she was doing to me and when I was charged by my insurance for the “procedures”, I went back to her staff for clarification. They were rude, raised their voice at me and would NOT listen to what I was trying to say. They were entirely unsympathetic to the fact that I was not informed about these procedures before they were performed.

Under no circumstance would I recommend this office. They are rude and have no appreciation for customer service. Needless to say, I will NOT be back.

Comment from Dina S. of Aglow Dermatology 11/11/2011This is a great opportunity to educate patients about  the “patient responsibility” aspect of health insurance.  Health insurance in a contract not just between the doctor and the insurance company but also between the patient and the insurance company and the doctor and the patient.  Nowadays, even patients with health insurance are finding that they are bearing more of the costs for health care as they are chosing high deductible health plans or plans with higher copay or coinsurance.  Many patients do not educate themselves about  their financial responsibilites and get angry  when they are properly billed by the doctor’s office for deductible, coinsurance, etc.  The doctor has a LEGAL obligation to collect these payments from patients if they are going to participate in insurance plans.  Patients are also legally obligated to honor their financial responsibilities in order to not be in violation of the insurance contract.  Unfortuantely, some patients who are not informed get angry and use forums such as Yelp! to vent and take a destructive course of action when in fact they simply don’t understand their own contracts.  We suggest that patient empower themselves and read their contracts and call their insurance companies if they have any questions._

Having to take time to understand one’s health insurance benefits can sometimes be annoying.  Your health insurance provider, however, can best help you understand your specific contract.  A doctor is responsible to understand his or her obligations and patients are responsible to understand theirs.  When everyone understands their part, I think patients will be happier and healthier.


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