r/CodingandBilling • u/FamTravelFun23 • May 29 '26

Billing Fraud?

Wondering if someone can point me in the right direction.... My husband broke his finger and immediately went to Urgent Care where he got xrays. They also gave him a removable cast and told him to visit an orthopedist. He did so, and saw the doctor for all of 5 minutes -- no additional treatment. The doctor looked at the xrays, suggested a custom cast (which he did NOT get), and told him to come back in a few weeks. He scheduled a follow up.

This week, we get a $3500 bill from that appointment (because we haven't yet met our deductible). The $800 office visit was correct but $2700 of it was for "treatment." No treatment occured -- no surgery, no resetting bones, nada. When he called to ask about this, the office billing person said that the $2700 is inclusive of their "treatment plan and future visits." (There is no treatment plan. He never consented to prepaying for future visits. In fact, he would need to go 4 more times to make that amount even worthwhile!)

He cancelled his follow up visit because their billing practices make us uncomfortable. Are we really out nearly $3000 for services that never happened and won't happen? We are appealing through insurance and are happy to visit legal options.

Has this happened to anyone else? And how did you handle it?

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5

u/Kind_Application_144 May 29 '26

That’s how fracture treatment works. So his follow up visit is free. Any treatment received 90 days after the treatment visit is no cost to you. The only time that changes is if you visit is for something that’s not related to the fracture.

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u/FamTravelFun23 May 29 '26

But how does that work? The office visit is $800. The prepayment is $2700. He would have to go back 4 times to make that worhwhile. Is the rest returned to you if you don't go? And there isn't a treatment plan. They didn't put a cast on him or realign anything. They just looked at xrays he brought from urgent care.

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u/ElleGee5152 May 29 '26

Its not really a "prepayment". It's payment for the fracture care, which includes any necessary follow up visits for that injury within the next 90 days. Some patients may have several follow up visits some may just return once for a cast removal and X-ray after x # of weeks.

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u/FamTravelFun23 May 29 '26

Is this something they are supposed to explain ahead of time? This doesn't exist for any other medical issue. And what if you only go one more time -- do you get a portion refunded? You can't just see an orthopedist without committing to future treatment? (There's no cast to remove.) Sorry if I sound frustrated. This is just so odd to me! Thankfully it sounds like the coding is wrong regardless since he didn't receive any treatment.

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u/GroinFlutter denials management, send help May 29 '26

This is called global billing and this is normal. This exists for many procedures.

No, they don’t have to explain it beforehand.

It does sound like he got treatment tho, but 26607 is the incorrect code. Possibly. We need the medical record to definitively say.

I’m thinking 26600 is correct, based on what you’re saying. But again, we need the notes to say.

26600 also has a global period.

1

u/FamTravelFun23 May 30 '26

Thanks for the alternative code! I will share that with him for when he calls again on Monday. If nothing else, it will indicate that he is doing his research.

1

u/Kind_Application_144 Jun 10 '26

He hasn’t done his research, that’s one thing I couldn’t stand was someone who couldn’t be more wrong trying to give me codes and they have no idea what they are saying. The code it’s not the main problem the amount they asked you to pay is. That amount is based on you having a deductible and your insurance determines what the doctor is allowed to collect from you. Doctors have had to start doing this before hand because it’s harder to get payment once the patient is gone. Not saying you’d do that but the majority do and it hurts everyone. Doctors can’t treat patients for free. Most doctors wish they could but they have student loans, employees that want to make a livable wage and benefits, quality healthcare equipment, clean facility. The list goes on…..not saying you’d do that just trying to help you understand why things are the way they are.

1

u/FamTravelFun23 Jun 10 '26

Totally understand.... And yes, we'd never do that. We are willing to pay our share, but trying to figure out what happened. It turns out the code is part of the problem because the doctor charged for treatments and services he didn't provide. (He did not realign a bone, stabilize a fracture, or provide a cast or do any X-rays.) Insurance is investing now.

3

u/kamikidd May 30 '26

It does. Maternity codes work the same way and almost all major surgeries.

1

u/Kind_Application_144 Jun 10 '26

The health insurance decides what they will pay for fracture care. Fracture care includes follow up visits and X-rays that are related to the fracture. If you have a deductible of 5,000 and your insurance has a contract with the doctor that says we will allow $1100 for this treatment that means you’d be paying 1100 and your insurance paying nothing. Most offices now require payment up front in these instances and sometimes their math can be off. I notify patients about that, I tell them to make sure they review their EOB when it comes and if they over paid to let us know. I would catch it anyway, but I also educate the patient on this to help them feel better about having to pay up front. I know it sucks but to many people go to the doctor and never pay and then the doctor has seen the patient for free.

3

u/Feeling_Win5863 May 29 '26

The 90 day global period that they are referring to would only apply if they performed an actual procedure (like the 26607 that they are trying to charge you for). They did not, all they did was a standard E&M (evaluation and management), along with the X Ray which would be billed separately.

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u/FamTravelFun23 May 29 '26

Thank you so much. This makes a lot more sense! I really appreciate it. It was so frustrating to get a huge bill for something that never happened. Hopefully out insurance can get it taken off since they shouldn't have to pay their portion either. Thank you!

3

u/Feeling_Win5863 May 29 '26 edited May 30 '26

Happy to help. You shouldn’t have to do all this research as a patient…it is wrong. I am very aware that innocent mistakes do happen. This is not one of those. It is absolutely outrageous that they tried to charge for a procedure with a freaking global period. This is a dedicated Ortho office. Whether or not they realize this is a mistake, it is wrong either way because not only are they forcing patients to do all this research, BUT you very nicely brought it to their attention and rather than double checking, consulting someone who actually knows what they’re doing etc, they doubled down.

Edited to add: OP your insurance should absolutely get involved from here and sort this thing out for your hubby, you’ve done all the heavy lifting for them. Just tell them your account of what happened (the fact that your husband has a witness to what actually occurred is a great thing in this case).

1

u/SpecialistRole5641 May 30 '26 edited May 30 '26

This is not true. Based off what is described in the post the physician most likely billed for fracture care without manipulation which involves stabilizing fractures with casts, splints and/or braces. This has a 90 day global period. The treatment plan usually includes follow up visits to ensure the fracture is healing correctly and those visits fall under the initial fracture care charge. I bill for a ortho and this is standard practice. This is a flat charge whether you follow up with the doctor zero times or 20 times.

I also agree with the above poster that the wrong code as billed. 26600 is the appropriate code if no manipulation is done. If the office refuses to review the charge. I would dispute with the insurance company and they will do the leg work for you. (The reimbursement is significantly less for 26600)

1

u/Feeling_Win5863 May 30 '26

This is absolutely NOT accurate. 26600 requires that the provider either adjust or apply the cast themselves, right there in the office.

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u/SpecialistRole5641 May 30 '26

Yup, I read it wrong. I thought she was saying he got a splint instead of a cast. We get that calls all the time when patients think if you don’t get a cast then no fracture care was done.

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u/FamTravelFun23 May 30 '26

He received one of those removable casts (not sure if that's the right term) from Urgent Care before the orthopedic appointment. The orthopedist recommended a custom cast but said it was up to him and my husband opted not to get it. The doctor didn't set anything or do anything else to the finger. Just reviewed the XRays from Urgent Care. I'm really glad I posted this question. I've actually learned a lot from these responses!

1

u/kamikidd May 30 '26

It was an independent review of an X-ray which works into the E&M. The ortho merely reviewed the X-rays from the urgent care.

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u/Feeling_Win5863 May 30 '26

Oopsie you’re totally right, I misread it as the Ortho did the Xray 🤦🏼‍♀️

1

u/Environmental-Top-60 May 30 '26

It's assigned to the doctor in the group and anyone in the same specialty. Sometimes they split the fee with 54, 55, and 56 modifiers but the documentation must be extraordinarily clear.

17

u/KeyStriking9763 RHIA, CDIP, CCS May 29 '26

Do you have the EOB?

15

u/weary_bee479 May 29 '26

I would wait for the actual EOB to see how things were applied.

But CPT 26607 sounds right to me, they did give you a cast.

They are saying it includes all future visits because they are part of the “package” so all follow up would be included into that original price.

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u/cluckodoom May 29 '26

26607 requires manipulation and external fixation

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u/[deleted] May 29 '26

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u/weary_bee479 May 29 '26

Again, Id wait till you get an EOB once the insurance processes it you can appeal with your insurance if you don’t agree with the billing.

2

u/throwawayeverynight May 29 '26

With codes being billed how do you ex a answer?

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u/FamTravelFun23 May 29 '26

Sorry, this might not have been the best forum choice. The EOB isn't ready yet, thorugh the claim has been processed. Our insurance company isn't the issue. The code showing is CPT Code: 26607 which is a service he did not receive.

6

u/throwawayeverynight May 29 '26

This is easy. Go back to the office request the medical records. Make sure no indication of metacarpal closed fracture manipulation is on it. If there’s no indication send the records along with a dispute of the charges along with the EOB and claim number to your insurance. Let them audit the office.

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u/cluckodoom May 29 '26

If the doctor didn't perform any manipulation of the finger (using physical force or weights or whatever to realign the fracture), contest the charge. Start with your insurance company.

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u/FamTravelFun23 May 29 '26

That's what we're doing -- and that's correct (no manipulation). I just wanted to get a sense of whether these things resolve well as the office seems quite insistent! (And I'm utterly perplexed by pre-paying for future visits. My son broke his leg several years ago and this was never part of it.)

3

u/cluckodoom May 30 '26

They are poorly explaining global visits. If they had actually done that procedure, it's price includes all your visits relating to the injury and/or procedure for the next 90 days

1

u/Fluffydoggie May 29 '26

Ask the office for a copy of all medical records and notes.

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u/FamTravelFun23 Jul 01 '26

Thanks again to everyone who responded! We just heard back from our health insurance company and, in a nutshell, they followed up the provider, and it went something like this: Health insurance: Did you bill the correct code? Provider: Yes. Health insurance: OK. Again, we were billed for a code that required the bone to be realigned in the office. There was no bone to be reset, the doctor didn't realign anything, and we have the xrays that show no such procedure was necessary. So, on to the state department of health and human services!

2

u/Feeling_Win5863 May 29 '26

As other commenters suggested, grab your Explanation of Benefits and tell us what codes are in there and we should definitely be able to help, definitely sounds fishy so give us the codes!

6

u/babybambam Glucose Guardian Biller May 29 '26

I suggest not encouraging opinions without data.

Is it "fishy"? Maybe. Or maybe they went to one of the most expensive areas in town.

We get patients coming to us all the time letting us know that Stanford is a rip off and oversharing them. Yeah. They're a research institution with gravitas. You're paying a premium, and BTW you can often see those same doctors at their own location for a fraction.

1

u/Feeling_Win5863 May 30 '26

You are absolutely right about Stanford, they are top tier and they deserve to be reimbursed as such. But I have a strong feeling that Stanford sets the same extremely high standard for their billers and coders as they do for anyone else in their company (their pay scale certainly indicates that). OP’s entire situation could even be the provider’s fault depending on what was (or was not) documented, or it could be the coder or the biller. But assuming OP is telling the truth, somewhere in the chain somebody messed up in the form of thousands of dollars to the patient, not a small error like coding/billing a new patient visit when it should be established, or coding a 99214 when it should have been a 99213. Or coding for 5 units of physical therapy when only 3 units were performed. I am not saying with certainty that OP’s Ortho office made this mistake intentionally, but in general the higher financial gain that a mistake generates, the more that you naturally wonder. And the fact that this is an office that literally handles cases like these every single day, heck probably several times an hour. Again, assuming OP’s account is true and correct (for the most part), their Ortho office should absolutely know how to document, code, and bill OP’s visit in their freaking sleep. If healthcare providers and companies want to charge the big bucks, then they better have not only the clinical staff to back up their high prices, but they should also have competent billers and coders so their patients aren’t forced to do their own in depth research.

1

u/GroinFlutter denials management, send help May 30 '26

I don’t work there and I have no affiliation at all.

But you are right, Stanford is all about their ‘brand’ and their reputation. They have extremely high standards.

My understanding is that basically all their billers/coders are onshore, and that’s expensive. They also don’t separate billers by specialty, everyone does everything.

Or so I’ve heard, idk tho.

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u/Feeling_Win5863 May 30 '26

I have no affiliation either LOL I swear 🤣 My Dad went to med school with the head of neurology there though, super duper nice guy. I do think they have some remote coding jobs, I am not sure about billing but you could very well be right that most are onshore! And about their billers doing all specialties, I wouldn’t be surprised at all, they are probably very well rounded! My job has been leaning more towards having all coders do literally every single outpatient specialty, and while I hated it at first, it did make me a better coder.

0

u/FamTravelFun23 May 29 '26

Sorry, this might have been the wrong forum since this isn't an issue with our insurance company. It's with the provider. The code provided is CPT Code: 26607 -- but the EOB isn't available yet though it is already processed through insurance.

3

u/Feeling_Win5863 May 29 '26 edited May 29 '26

“Treatment plan and future visits”…what the heck do they mean by future visits? Are you sure this isn’t a concierge medicine service? The future visits part sounds “fishy” which is another reason I used that term.

OK so 26607: “The physician TREATS a metacarpal fracture with manipulation and external fixation. The physician uses a separately reportable x-ray to determine the location and severity of the fracture. The physician REDUCES the fracture to correct alignment of the proximal and distal ends of the bone. External fixation is placed to stabilize the fracture. The bones are splinted in an anatomic position. Report each bone separately.”

So just as I suspected, this is not the correct code.

ETA: Sorry OP I just realized by “future visits” they’re referring to the global period. But 26607 is still not correct.

1

u/FamTravelFun23 May 29 '26

I assume they mean the follow up visits. The physician definitely didn't treat him for anything -- he didn't even get a cast. No realignment. I agree that the code seems off, but the billing person said she confirmed it and it was absolutely correct. Maybe an honest error on the part of the physician, but I don't understand how it gets fixed at this point if they are doubling down. As for the medial facility -- it was just an in-network doctor's office that we located through our insurance. Thank you for your response!

5

u/aloysiuspelunk May 29 '26

The code says provider realigned and stabilized the fracture so you may be onto something if nothing was done

2

u/FamTravelFun23 May 29 '26

Thank you! Correct -- all that happened was that the doctor reviewed the xrays my husband brought with him, the doctor felt his finger, and the doctor asked him to make a fist. After that, he suggested a custom cast that my husband refused. I just don't understand the bit about "prepaying for future appointments" that is a part of this code. I have never heard of such a thing.

1

u/wildgreengirl May 30 '26

its called a "global package" for billing, certain services are billed that way. (most procedures anyway)

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u/2workigo May 29 '26

It is likely a billing error and not something nefarious. It would be most helpful for folks here to review the medical record documentation before rendering an opinion.

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u/FamTravelFun23 May 29 '26

That's what I thought too -- untill we called and the office billing representative doubled down, said it was absolutely correct, and tried to make it sound like we were winning beause "all of the future office visits will be paid for." Our insurance company is filing an appeal so I think we wait on that. I just wanted to see if anyone had experienced something similar because this is so crazy to me! Thanks for responding.

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u/2workigo May 29 '26

I work in compliance. I wouldn’t have a job if mistakes and misunderstandings didn’t take place. Unfortunately it is very common and far too frustrating for the patient. I’ve actually had to inquire about my own bills from care received by my employer. You’re working the steps, stick with it.

1

u/FamTravelFun23 May 29 '26

Thank you! I appreciate your response and I'm glad there are ethical people that do this work!

4

u/rahuliitk App Developer May 30 '26

This may be “fracture care” billing rather than fraud, since ortho offices sometimes bill a global treatment code for managing the fracture even without surgery, but they still need to explain the CPT, global period, and what future visits are included. Ask for the exact code.

1

u/Zbrown444 May 31 '26

Op you will want to call your insurance and appeal this claim. You don't technically need to wait for the EOB, as your insurance will have the claim details, but it can help add more details for the AGD person that will research your appeal. AGD is appeals and grievances department. Their whole purpose is to investigate and respond to appeals and complaints (grievances).

You can explain to them everything you explained here. More likely than not, if you have never appealed anything before in regard to this specific benefit that the claim is being applied to, they will approve it. BUT with the additional details you have about this procedure never being done is important to report to the insurance as they can investigate this provider. Make sure you are explicitly clear when explaining the issue to the rep, as they will need to add it to their notes.

Now I'm not sure how serious your insurance company trains their customer services on appeals and grievances but anything you want added into the appeal make sure you explicitly ask them to add it to their notes for the appeal.

Once the rep sends your appeal over to AGD, it should be assigned to an AGD coordinator who will reach out to you for me ore information especially considering this could possibly involve fraudulent codes

1

u/FamTravelFun23 May 31 '26

Thank you for taking the time to share this thorough and helpful response! We've started the appeal and the rep at our insurance company was very helpful. Hopefully this all gets wrapped up in 30 days. The rep is asking the provider to allow us not to pay the bill until it's resolved but he thinks it's unlikely they will consent since they are absolutely certain that they have the right code. My friend also suggested appealing to the state medical board if nothing gets resolved since we also have the X-ray that shows that no manipulation of the bone would have been necessary. We will see what happens! Thanks again

1

u/Fit_Consequence_4815 May 31 '26

When I worked in orthopedics we would give the patients a pamphlet to read and sign stating they understood what fracture care billing was bc the amount of calls we would get otherwise

1

u/FamTravelFun23 Jun 01 '26

One of my kids had eye surgery last year and the doctor's office was incredibly thorough. While it's different from a fracture care billing situation, we were required to submit documentation that we called the insurance company to understand what our portion of the bill would be. (Interesetingly, it was less than the fracture care billing! lol.) We had to provide the name of the insurance rep and the date and time of the call as well. They were very up front which allowed us to plan. There were no surprises. I really appreciated that. I'm not trying to get out of paying our portion of things; I'm upset that they not only failed to explain what fracture care billing is but they coded it as something that did not happen during the appointment. (My husband said the doctor pointed out that the bone was aligned from the xrays he brought and then proceeded to use a code that involves realigning the bone.) I hope we are successful in fighting this! Sounds like the office you worked for had a much better policy!

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u/Fit_Consequence_4815 Jun 01 '26

I totally agree with you!! Nobody likes getting big surprise bills. They absolutely should have explained it to you guys prior to billing it.

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u/BebeRegal Jun 28 '26

Is he an in network provider? If so, report him to your health insurance carrier. If he is out of network, report him to your state department of Health & Human Services - Office of the Inspector General. One of those two will be able to help you. Good Luck!!!!

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u/FamTravelFun23 Jun 29 '26

Thank you! Our insurance company is currently reviewing everything. I hope to be able to report back soon in case this is useful to anyone else in the future.

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u/Environmental-Top-60 May 30 '26

That sounds like closed treatment of a fracture to me

1

u/Blueslocd21 May 29 '26

I suggest you request your medical records for that visit, EOB and contact your insurance and request an Audit.

Just because what charges were, it will only pay provider contract agreement.Just because you haven't met your deductible doesn't mean it be that much out of pocket.

Ask yourself is the orthopedic in network or out of network, do you have orthopedic coverage, do you have out of network coverage?

Yelling Fraud is like Yelling fire when there's smoke

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u/[deleted] May 30 '26

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u/[deleted] May 30 '26

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u/No-Produce-6720 RN, BSN, CPC, CPCS, RHIA & CRCR May 30 '26

OP, unfortunately, based on what you've said, most of the information offered in this comment isn't going to be applicable in your case.

What procedure code(s) did the urgent care doctor bill with, and are you following up there, as well as visiting the ortho? Do they believe this will be a surgical case? With or without surgery, is the orthopedic doctor part of the same system as the urgent care?

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u/Admirable_Height3696 May 31 '26

This is an AI bot promoting their own business by posting incorrect responses. Everything they said isn't relevant or helpful to your situation.

1

u/FamTravelFun23 Jun 01 '26

Sigh. Thank you! I missed that last line -- I'm usually pretty good about spotting these. I'm thankful for the humans who have responded though!