Who Are the Healthcare System's Worst Offenders of Fraud - Part 1

I found out firsthand where the fraudulence and waste is in our healthcare system. My experience with doctors, hospitals, and healthcare providers, proves that they are the worst offenders.

My oldest is now twenty-six years old. However, a trip to the pediatrician eighteen years ago is a memory that will stay with me forever.

I took my daughter for her annual checkup, or well visit as they called it then. At the time, our family used one of the HMO plans. It was a plan we recently chose because our employer no longer paid for our insurance. This plan, out of the ones we had to choose from, seemed the most economical and practical for our family.

The visit to the pediatrician only lasted about thirty minutes. We paid our co-pay to the receptionist and my daughter received a clean bill of health. I thought that was the end of it, but I was sadly mistaken.

Several weeks after my daughter's visit, I received a bill from the pediatrician, totaling over $300.00. The bill was not itemized. I could not tell what they charged me for, and did not know how to defend myself. I thought the bill had to be a huge mistake on someone's part. Our medical coverage included all costs related to annual visits.

I immediately called the pediatrician's office and politely asked why they sent us the bill for my daughter's visit, when we had medical coverage. The receptionist told me that my insurance provider did not pay for all of the expenses incurred during that visit.

That led me to believe that I made the wrong career choice. I told the receptionist that I regretted not going to medical school and becoming a pediatrician. If a pediatrician could charge more than $300.00 to stick a tongue depressor in a child's mouth, and for the receptionist to record her height and weight, I wanted in on the action.

The receptionist did not believe that my comment was funny, and she rudely told me to contact my medical insurance company. She instructed me to ask them why they only paid a portion of the bill.

I thought, "Why not? What have I got to lose?" I figured I did not have anything to lose. I was right. What I gained was a wealth of information about how medical fraud is committed, not by patients, by doctors, or at least, by this doctor

When I spoke to a representative of my healtcare provider, and she told me that my plan did not cover certain tests performed on my daughter during her visit to the pediatrician. I could not imagine what tests the pediatrician would have performed on her, as she was not sick at the time. This visit was only a checkup. I asked the woman to send me a copy of the claim that the pediatrician sent them. I pretended to behave as though I believe the insurance provider mixed up my daughter's records with someone else's. She told me she would gladly do that for me. Now is where the story gets even more interesting.

Once I received the pediatrician's bill from my healthcare provider, I understood what transpired. There was no mix-up. One of the tests, among a host of others, was one the pediatrician claimed he performed, to rule out 'UTI', urinary tract infection.

My healthcare provider apparently did not feel this was a test important enough to cover. Besides the fact that the test was an unnecessary one, the pediatrician never performed the test at all.

I had to stop to ask myself two questions:

1-Why would the pediatrician perform a test to rule out a urinary tract infection when my daughter had no symptoms for that particular ailment?

2-More importantly, if a pediatrician suspected that my eleven-year-old daughter might have a UTI, would that be something I should know about?

I called my husband to explain the situation, and I then asked him this question:

"Does this sound like fraud to you?"

Before he could answer, I told him I had to hang up and make another call. I contacted my insurance provider, and told someone there what had happened with the pediatrician. I also wrote a letter to the American Medical Association, explaining in detail what the pediatrician did. They did not even have the decency to respond to my complaint.

Moreover, my healthcare provider did not know what to tell me, except to say to disregard the bill. I did not have any other choice but to drop the matter. Who else was there to complain to but the American Medical Association?

To this day, I cannot understand why they ignored my letter. They could have at least called me to tell me that I must have been mistaken. Even if they would have lied and told me they would look into it, it would have felt better than having them completely ignore me.

Nevertheless, I became an overseer of all things medical when it came to my children. I also switched pediatricians, several times, until I found one I liked. Believe me; it was not easy.

Nothing else involving a member of the medical profession occurred, until twelve years later when my daughter sprained her ankle on a college campus, two weeks after graduation.

More to come:

The nightmare continues in Part 2 of, "Healthcare's Worst Offenders of Fraud and Waste ".