When Copay Saved The Day

, , , , , , , | Legal | November 6, 2019

(This takes place after I receive a statement from my medical insurance company, who is also my provider.)

Agent #1: “Thank you for calling [Company]. My name is [Agent #1]. May I please have your name and insurance number?”

Me: “Hello, my name is [My Name], and my number is [number].”

Agent #1: “How may I help you, Mr. [My Name]?”

Me: “I am calling about the statement that I received in the mail recently. There are several charges against my insurance that I don’t recognize. Those are the charges from [dates], for [amounts].”

Agent #1: “So, you are claiming that you did not make these charges?”

Me: “Yes, those are not my charges, and no one else has my insurance information.” 

Agent #1: *suddenly defensive* “So, are you saying that someone here at [Company] ran charges against your insurance? Could it be more likely that you gave your insurance card to someone else, and now you are trying to rip us off? I don’t know what you did, but we are not responsible for what you do, and we aren’t going to help you defraud us!”

(My insurance is very good; my copay is never more than $20 for Schedule 2 drugs and surgical procedures. Regardless, the accusation infuriates me more than the insurance fraud.)

Me: *furious, but keeping my temper in check* “Now you can transfer me to your manager.” 

Agent #1: “Why? So you can lie to her, as well? I’m not going to let you try to rip off [Company] anymore. Don’t call back or I’ll give your number to the federal government for insurance fraud!” *hangs up*

(By this point, I am absolutely furious and am about ready to call National Insurance Crime Bureau myself, but I decide to try one more time.)

Agent #2: “Hello, thank you for calling [Company]. May I have your name and insurance information?”

Me: “My name is [My Name] and my number is [number].”

Agent #2: “How may I help you today?”

Me: “Does the word HIPAA mean anything to you?”

Agent #2: *slightly confused* “Yes, of course. Every medical company follows HIPAA rules.”

Me: “Apparently not.” *explains situation* “Now, the first agent accused me outright of giving my insurance to someone else. I, however, have to wonder how your company gave my private medical information to some random person. That is a major HIPAA violation.”

Agent #2: “If you’ll hold for a moment, my manager wants to speak with you about this.”

Manager: *taking the line* “Hello, my name is [Manager], and I understand you have some issues with some charges against your insurance?”

Me: “No, I have issues with what your company has done, by the admission of your own agent and the charges I see here. There are charges on my account that I didn’t make. Now, one of two things happened here. One, someone else was allowed to use my insurance information to schedule an appointment, see a doctor, and get several high-class prescriptions, all without checking to see if they were me. That would be so many HIPAA violations I can’t even count them all. Or two, someone in your company is scamming insurance for money or drugs. That would be insurance fraud, in which case I would be within my rights to sue.”

(The manager is suddenly quiet, followed by the sounds of typing. When she comes back on the line, she sounds a little shaky and nervous.)

Manager: “If you’ll just bear with me for a little bit longer, I think I might know exactly what happened. Can you please confirm the dates, doctor’s name, and pharmacist name listed on your account?” 

Me: “The dates are [dates], all of them are listed as being with [Doctor], and the prescriptions are all listed as filled by [Pharmacist].”

Manager: *eerily calm now* “I think I have found the problem. Please give me a phone number, and I will call you back as soon as I get what I need.” *gives my number* “Again, my name is [Manager] and my direct extension is [number].” *call disconnects*

(She called me back about three hours later and explained everything. It seems that it was, in fact, insurance fraud: hundreds of thousands of dollars worth of it. From what the manager told me, the doctor, the pharmacist, and [Agent #1] were all family. It seems that they had been running a MASSIVE insurance scam, one where the doctor ran up fake appointments against insurance, usually avoiding triggering patient copay by billing it as a copay-free appointment. He would then write prescriptions, also against insurance, which would then be filled by the pharmacist, also his sister. They would then take those prescriptions and sell them for a much lower price and pocket the money. [Agent #1]’s job, it seems, was to direct patients away from any suspicion. Usually, he succeeded by claiming it was some type of hidden fee, but that insurance would handle it and there would be no charges for the patient. They messed up this time, though; my insurance is through the state, and one of the prescriptions that the doctor wrote automatically triggered the copay on the state insurance plan, thus my problem. This manager just happened to notice the family connection, and, when she opened the records, she put it all together from the appointment records. Things drug on for a while, and the doctor tried to run once the feds started investigating, but in the end, all three were arrested. Last I heard, they are all facing very, very long sentences. As for the charges? They were reversed with no difficulty by the manager who took my call the first time.)

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