Excessive lab charges to Mom's insurance. Surely this has to be blatant fraud!?

Is your mother (or you as POA) getting billed exorbitant amounts of money for these tests? Medicare and the secondary insurance should have a CAP on how much you actually pay for lab tests. Unless you are being asked to pay lots of money for this testing, I'd ignore the charges on the EOBs and allow the insurance company to fight it out with the lab.

In 2008 I had spinal fusion surgery on my neck; I was in the hospital for 24 hours. The bill was $249,000.00. I was flabbergasted and immediately felt like the bill was fraudulent. I called my insurance company who was United Healthcare at the time. The representative laughed when I expressed my concern at the exorbitant bill. She told me not to worry, that ridiculously high bills were part of the game the hospitals played with the insurance companies! I was irritated, to say the least, thinking I was doing a good thing, only to be laughed at.

My mother has lived in MC Assisted Living since June of 2019 and has had lots of lab testing over the years, including mobile lab testing where the company comes into the MC with their equipment (which is extra costly). Never have we paid more than our contracted co-pay for any of the services in all this time.

If I were you, I would not spend hours on the phone calling Medicare and trying to prove you're the POA and all that jazz. Just wait to see if you get some outrageous bill FIRST before you freak out. If not, just let the lab and the insurance companies duke it out; it's between THEM, really, you know?

This is what I think is happening. The lab is coding it wrong and they are trying to fix it to get Medicare to pay. As long as the Lab has not billed you, let it go for now. You really can't do anything till you get an actual bill. Have you not received a statement from Medicare saying the charge was not covered and the reason why? Medicare sends a statement, the secondary sends a statement. You should be making sure these agree but the suppliment statement due amount should agree with what the lab bills you.

This is how it works. The lab bills Medicare lets say $1000. Medicare approves $600 (lab has to except this if a Medicare lab), Medicare pays 80%, $480. That leaves a balance of $120 which Medicare sends onto the suppliment of record who then pays all or part of the $120, depends on the contract Mom has with supplimental. If Medicare turns down the charge, so will the supplimental. If Mom has A&B her labs are covered.

Again, there is probably a coding problem. This is the Labs problem to fix. Now, when it comes to Medicare and lab work, Medicare pays the Lab hardly anything. You need to wait for the billing from the Lab to get this straightened out. That billing should show what Medicare paid and what the suppliment paid. Like I said, not all suppliments pay the 20% Medicare does not pay. With mine, we are on a share plan and you have deductibles that have to be met.

If the billing seems outrageous, then u call Medicare. A provider who can bill Medicare has to except what Medicare pays. With my example its the $600. Medicare paid 480 leaving a bal of $120. If the supplimental does not cover that $120, let say it went toward Moms deductable, then Mom owes that $120.

I would ask that no labs be done on Mom without consulting you first, especially if you have POA. There are rapid COVID tests that can be done and more accurate PCR. Under government guidelines, these should be free of charge. They should not be doing these tests at random. Mom needs to have been exposed and I think showing signs. Your local health dept can tell you. IMO the director has no idea what he is talking about. If its a COVID test that is all that the lab should be testing for. My daughter just got her statement and the charge for COVID testing was $600 by the lab but her insurance paid it. There will always be a charge by the provider, but between Medicare and secondary insurance it should be covered.

Talk to your Mom's doctor, nurse practioner about the lab work. Who order the labs and why? What exactly is being tested? Who gets copies of the labs besides the facility? How often do they plan on testing? As needed-then need must be established-and approved by her doctor, not just the facility. Monthly testing? Still demmand that that be approved by her doctor and that you are kept in the loop about this.
About the "double billing"-sometimes this happens when one billing period ends and the next one begins and perhaps who ever entered the information about the labs didn't click on the next tab to start the next billing cycle. When this happens to me, I'll call them and ask if it's ok to wait a few weeks until the cycle sorts itsself out-never had a problem doing that.
Do you have power of Attorney? Makes a huge difference in stuff like this. As well as an elder specialist lawyer too, just to make sure you're doing the right things legally in your state.

Call the insurance company. There should be a number on the EOB to report fraudulent claims.
A couple of years ago there was a scandal about one of the major labs. They were billing routine tests, like a CBC, as individual tests; Red blood cells. White blood cells, liver function, kidney function, etc. So instead of one charge to the insurance company for, say $75, they were billing each component out at $75.

I would call medicare fraud division and ask for an investigation. You may want to let the ALF know you plan to do this. If she has supplemental insurance you may need to speak with them as well. These are bills to your grandmother for her care. Failing to pay them may ruin her credit, but realistically how much credit scoring does she NEED at this point. Keep at them. Good luck.

I am going thru with this with a hospital. My tests were turned down because Medicare said this facility is not covered for this service. A HOSPITAL! It was a mammogram and scan. I gave my info to the girl at the Hospital when I made my appointment and again when I was admitted. If there was a problem with insurance admitting would have told me when I arrived. I just had a colonoscopy at the same Hospital and everything has been paid to the doctor thru Medicare. I "know", its a billing error on the hospitals end. They will just have to resubmit. Until I get an actual bill, I am not worrying about it. Statements aren't bills.

Believe me, you can't really do anything until they actually bill you. Its not fraud till they bill you. Statements can be wrong and they can be adjusted. They can charge anything they want to, if they except Medicare they also except what Medicare thinks is reasonable. I still think the Lab is trying to correct a billing error on their part by constantly by re-submitting the original claim. It comes down to the Lab has a lousy medical billing clerk who is coding that lab wrong and Medicare is not excepting it. As I said Medicare pays very little towards labs, very little. And you cannot be billed for more than Medicare considers reasonable.

Just wait for the bill. Don't call anyone until you receive it. If it still seems unreasonable, then look at the Medicare statement and the secondary statement to see how they paid. Again, a secondary only pays the 20% of what Medicare has paid. If Medicare has turned down the claim, so will the secondary.

The one problem I have with Medicare is they send out a statement for each service provider they have paid. Then they send out a Summary listing again All the services u had done within a certain time frame. Like a duplicate. For me this is really confusing because when I get a bill I don't pay it until I get the statement from Medicare and my secondary. If the bill totals what Medicare and my secondary say, I pay it and throw out the statements. I don't need any summary.

Fraud or somebody has a really wonky computer program. Talk to the administration about the bills - and make copies to show them what you are concerned about.

Your state's Attorney General's office would look into alleged fraud; no reputable business wants that kind of scrutiny but sadly there are less than 'efficient/honest' actors in every sphere.

When you get multiple EOBs for the same dates of services, previously denied that is a reprocessed claim. They billed for multiple things and the insurance needed the right cpt codes and modifiers for the claim to process correctly. Now fun fact if you contact insurance they can not tell you HOW to Bill (rules).... Meaning if your 22 year old twit of a biller doesn't know what she is doing she will just on resubmitting until they get paid. Fraud maybe........I shut down the skilled nursing facility for violations and turned in my home health for Medicare fraud so possible but those were 20k in over billing in one month and services never rendered. Every test should have a result simple ask for All results if it's a lab. Double billing or fraud it's hard to create results easy to Bill though.
Itemized

Contact insurance company and let them sort it out. That's the best you can do.