3 ms·

It's obviously fraud. If your windshield breaks and your deductible (co-pay) is $500, I can't quote you $500 above market rate to fix it and give it back to you

by aianus 10y ago

It's obviously fraud. If your windshield breaks and your deductible (co-pay) is $500, I can't quote you $500 above market rate to fix it and give it back to you in cash to stick it to your insurance company.

Declanomous 10y ago
Somehow there is a mechanic shop near me with a sign out front advertising that they will pay your deductible. It's not exactly hidden either -- it's located on one of the busiest streets in Chicago. Here's a street view image: https://goo.gl/maps/hUAUUEJwiQT2 https://goo.gl/maps/hUAUUEJwiQT2
- aianus 10y ago
  If the real cost to fix a windshield is $300 but your shop advertises $800 to everyone along with an offer to 'pay the deductible' then it's not illegal. You can claim your shop is more expensive because it offers better service or better parts or whatever. It would only be illegal to quote $300 for those who are uninsured but quote $800 for those who do have a deductible. It's still clearly a scam against the insurance companies, whether actual fraud charges would stick in court or not.
FireBeyond 10y ago
Your deductible is not your co-pay. Deductibles, co-pays, and co-insurance are all separate things with specific definitions: A deductible is a portion of covered medical expenses that the insured must pay. It is specifically defined as the amount of covered benefit that must be incurred and paid by the insured before benefits become payable by the insurer. Key in the above is "a portion of covered medical expenses". A copayment is a flat dollar amount that the insured pays each time a certain kind of service is received. The copayment is not a percentage of the total cost, as it is in coinsurance, but rather is always the same dollar amount even though the cost of the service may vary (a pharma co-pay of $x, regardless of the variable drug price). It may seem like nit picking, but there are specific reasons for the difference. Source: myself, who writes and maintains health insurance claims management and adjudication software. This is all separate to your claim: of course, if your doctor agreed to charge you $x+200 (leaving aside the reality of negotiated and contracted fee schedules) and refund you that $200, then absolutely yes - this is insurance fraud. However, the co-pay does not form part of the insurance coverage.
- aianus 10y ago
  > This is all separate to your claim: of course, if your doctor agreed to charge you $x+200 (leaving aside the reality of negotiated and contracted fee schedules) and refund you that $200, then absolutely yes - this is insurance fraud. If you charge $X more for an Epipen vs. the market rate for a generic epinephrine autoinjector but offer a $X discount for uninsured persons (or a smaller $Y discount for those with copays or deductibles), it is the same scam. Maybe not legally, but effectively.
  - FireBeyond 10y ago
    What you need to remember in this case is that the delineation comes FROM the insurance company. They wash their hands of the co-pay entirely and say "no, we+your deductible are covering this (part of the cost)". That becomes the insurance benefit in total. Your co-pay also comes out of your pocket, entirely separately. There's no fraud, because that's how the insurer defined the separation themselves (for other reasons).

by aianus 10y ago

Declanomous 10y ago

Somehow there is a mechanic shop near me with a sign out front advertising that they will pay your deductible. It's not exactly hidden either -- it's located on one of the busiest streets in Chicago. Here's a street view image: https://goo.gl/maps/hUAUUEJwiQT2 https://goo.gl/maps/hUAUUEJwiQT2

aianus 10y ago
If the real cost to fix a windshield is $300 but your shop advertises $800 to everyone along with an offer to 'pay the deductible' then it's not illegal. You can claim your shop is more expensive because it offers better service or better parts or whatever. It would only be illegal to quote $300 for those who are uninsured but quote $800 for those who do have a deductible. It's still clearly a scam against the insurance companies, whether actual fraud charges would stick in court or not.

FireBeyond 10y ago

Your deductible is not your co-pay. Deductibles, co-pays, and co-insurance are all separate things with specific definitions: A deductible is a portion of covered medical expenses that the insured must pay. It is specifically defined as the amount of covered benefit that must be incurred and paid by the insured before benefits become payable by the insurer. Key in the above is "a portion of covered medical expenses". A copayment is a flat dollar amount that the insured pays each time a certain kind of service is received. The copayment is not a percentage of the total cost, as it is in coinsurance, but rather is always the same dollar amount even though the cost of the service may vary (a pharma co-pay of $x, regardless of the variable drug price). It may seem like nit picking, but there are specific reasons for the difference. Source: myself, who writes and maintains health insurance claims management and adjudication software. This is all separate to your claim: of course, if your doctor agreed to charge you $x+200 (leaving aside the reality of negotiated and contracted fee schedules) and refund you that $200, then absolutely yes - this is insurance fraud. However, the co-pay does not form part of the insurance coverage.

aianus 10y ago
> This is all separate to your claim: of course, if your doctor agreed to charge you $x+200 (leaving aside the reality of negotiated and contracted fee schedules) and refund you that $200, then absolutely yes - this is insurance fraud. If you charge $X more for an Epipen vs. the market rate for a generic epinephrine autoinjector but offer a $X discount for uninsured persons (or a smaller $Y discount for those with copays or deductibles), it is the same scam. Maybe not legally, but effectively.
- FireBeyond 10y ago
  What you need to remember in this case is that the delineation comes FROM the insurance company. They wash their hands of the co-pay entirely and say "no, we+your deductible are covering this (part of the cost)". That becomes the insurance benefit in total. Your co-pay also comes out of your pocket, entirely separately. There's no fraud, because that's how the insurer defined the separation themselves (for other reasons).