Jacksonville, FL asked in Civil Litigation, Public Benefits and Health Care Law for Florida

Q: Can psych offices legally agree to one contract rate with one insurance company then submit secondary claims to Medicare

Situation: Psychiatric Office has an agreed upon contracted rate with my wife’s insurance company for $81 a visit (she also uses the same office) they primary insurance company tells them to not collect anything else from the patient (no copay) THEN the office submits a claim to Medicare (even though Medicare is unnecessary because there is an agreed upon contract with the first insurance company that pays the contracted rate. Medicare not only pays more money but ALSO tells the psych office to not collected anything else from the patient. Psych Office then comes to patient and insists on copays on random visits or says patient has a balance. Patient is on disability for Bipolar disorder ll , PTSD, anxiety, and learning disorders. Patient realized that the Psych office is collecting their normal $250-$300 an hour rate by taking the $81 agreed upon contractsd full amount and then having Medicare and patient make up for the rest even though it’s supposed to be the one rate. Is this legal

1 Lawyer Answer
Charles M.  Baron
Charles M. Baron
  • Hollywood, FL
  • Licensed in Florida

A: That office might be a Medicare fraudster (engaging in crimes), or this could be legitimate under the insurance policy and Medicare rules. You should first ask the office (in a friendly way) for its explanation for their billings, and if the explanation doesn't make sense, tell them so and see if they are able to give a rational answer. If they say, "your insurance company has this information, talk to them", then do that. If you receive no information that justifies their actions, contact Medicare. See https://www.medicare.gov/basics/reporting-medicare-fraud-and-abuse

Of course, if you complain to Medicare, your wife may no longer be welcome in that office.

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