Is this billing fraud legal? (California) (California) (Cali

This category is meant for discussion of technical legal issues in workers' compensation. If you are an injured worker, do not ask questions here. Go to the Injured Workers' forum.

Is this billing fraud legal? (California) (California) (Cali

Postby 4anewusers on Tue Dec 17, 2019 7:41 am

Question: How are some medical providers in workers compensation getting indicted for over-billing when according to this article it is a common practice and legal? ... i=80486938
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Re: Is this billing fraud legal? (California) (California) (Cali

Postby jpod on Tue Dec 17, 2019 1:50 pm

The article is about health insurance billing not workers' comp. Workers comp is not private practice, ii is a state mandated program that imposes rules; there is an official medical fee schedule and a requirement that medical services be both reasonable in terms of cost AND medically necessary. In WC Medical providers are not allowed to enter into a contract with the WC patient.

In health insurance the doctor can set their own fees which does not necessarily match the amount the health insurance covers. The patient usually signs papers which is essentially an agreement to pay the doctor the difference between what was billed and what the health insurer paid to the doctor.
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Re: Is this billing fraud legal? (California) (California) (Cali

Postby mvucurevic on Wed Dec 18, 2019 8:17 am

To answer your question in the simplest form, the Doctor's who are being indicted for "over-billing" are actually being charged with billing for items and services that were never provided. With regards to "over-billing" the provider is really required to do only one thing and that is bill every payer the same charge, be it Medicare, an insurer, or the patient.
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