Payback is a *****!

YES! I finally received my insurance reimbursement check from the Insurance Company…ALL OF IT!
The approximately $800 I received back was much more an emotional and psychological victory than a cash reward (plus I paid that money out to a very unethical therapist 5 years ago!)
If you haven’t read my other blog entries and know the history… I’ll give a quick synopsis of the story.
Back several years ago I had gone to a therapist during a divorce and while supporting very ill family member, now deceased.
The therapist committed insurance fraud 2 ways….the first was in 2006 (for sessions in 2005) by telling me my insurance company denied his claims and that I owed him for the sessions. This turned out to be a blatant lie as I later found out. He had never filed the claims. This is a form of health insurance fraud performed by billing a client more than the amount of a copay for services that are fully covered under a managed care plan.
The second way was by triple billing my insurance for 10 sessions in January 2007 when we only had three, and double billing my ex-husbands insurance during the same time period. ( He had to pay back the insurance company for those and withdraw as a provider)
The check I received was reimbursement for the first fraud  If I paid myself for the number of hours I spent reporting the fraud to the insurance company, filing a licensing board complaint and then dealing with getting money back from the insurance company ( the therapist had to submit billing at the insurance company’s request for those sessions in 2005)…..I probably made about minimum wage but getting that check back was an emotionally and psychologically priceless!

3 Responses

  1. Wow! I am glad that you received a victory of sorts…and a validation, too, I would think.

    I am unclear as to why they paid you since it was really the therapist who owed you, right? Was it, perhaps, a reward for turning the guy in?

    Whatever the reason…I think it is awesome!

    • No ,it wasn’t a $$$ reward….wish their was such a thing (that’s a whole other subject!)….then maybe therapists who committ fraud would think at least twice!

      Yes, Mr. LR, the therapist “should have been” the one to pay me back. However, the only thing he did was offer to write a check to a charity in my name….nice guy , right :) would have been the honest forthright thing to do…….but he also never provided me with a bill or receipts….this wouldn’t happen today!….but I allowed it then. (eventually Anthem had him submit an “email” bill for the services….guess the putz finally figured out that submitting fraudulent claims through the US mail is a crime….and since Anthem “could” go after him for fraud, he’d be placing himself in jeoprady.
      Also recall. this is the same guy who had later triple billed my insurance, and double billed my ex-h’s for sessions that never occured!)

      For this story though…. here’s how the insurance company comes in… contract for health care is with Anthem and I used the services of a provider contracted by them. My contract states (as all other managed health care contracts do) that a provider can not charge to a member more than the copay amount for services covered in full under a managed care contract. …This is one form of “health care fraud”, and violated my contract with Anthem. So the insurance company was responsible to me as a member for the terms of my contract with them ….and Mr. LR the therapist was responsible to Anthem for the terms of his provider contract.

      So I received the money I paid him back, as Anthem did not really want to see me in court for breach of contract!

      So now it is up to Anthem to pursue the therapist for insurance fraud and to get their money paid to me, back from the therapist. I’d love to know if they choose to do so, but will have no way of finding out unless they “fully investigate” him, and find he committted fraud on a grander scale than against, just myself and my ex.

      Yes,very happy for the priceless moral victory!

      Another side note….the only way I had “proof” that these sessions happened was due filing to an Freedom of Information request, after the first go ’round of the Licensing Board case….I had received in that request all of my “allleged psych notes” which were worthless psychobabble…..BUT did contain all the appointment dates, with my name on the page and the Mr. LR’s signature. If I didn’t receive these I would have had no proof of service to present to Anthem to get the money I paid him back!
      What was funny ….is that I had also received as part of the FOIA request ALL the information about Anthem’s fraud investigation ( regarding the triple billing). Anthem’s representative said to me in one phone conversation…”You have information your not supposed to be privy too”….to which I responded….”oh, well! I asked for the whole file and they sent it” I just laughed as I think mit’s ridiculous how insurance companies claim to want to prevent and reduce health care fraud, but at the same time cover it up and don’t prosecute it whenever possible.

      So that’s the “short version! Thanks for asking, it’s always helpful to talk and write about it!

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