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Pediatrician refuses to see my daughter, what action should I take?

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Pediatrician refuses to see my daughter, what action should I take?

Old 09-23-08, 01:10 PM
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Pediatrician refuses to see my daughter, what action should I take?

Our daughter has been seeing the same pediatrician since she was born (July this year). Two nights ago our daughter wasn't sleeping so well, we suspected a mild cold. In the morning my wife called the pediatrician's office to see if it was necessary to take our daughter in. They told her to go in just to be safe.

Upon arrival, the receptionist admitted that due to standard paperwork that the pediatrician failed to complete on time with our insurance company, that all our claims were being denied. As a result, our pediatrician would not see us unless we paid in full for the visit AND we also owe her for all previous claims that were denied. This entire time the receptionist kept on apologizing and said it was the pediatrician's call and there was nothing they could do. They offered another pediatrician in the building that our insurance accepted, luckily he turned out great and we may continue to see him instead.

In my mind, I think it's unethical to refuse to see my daughter due to a mistake in paperwork on her part! The entire time that my wife was talking to the receptionist, she said the pediatrician never once came out to explain what was going on.

So now, I'm trying to decide whether it's worth pursuing anything against the original pediatrician. Keep in mind, I haven't received a bill for previous visits yet, and I haven't spoken to the pediatrician myself, I'm giving myself some breathing room so that I can keep my anger in check.

1) California Medical Board- I'm thinking of filing a complaint against the pediatrician for patient abandonment. If I read this correctly a patient is suppose to be informed in writing 15 days before denial of service, along with other information regarding alternative sources of medical care and how to obtain medical records.

http://www.medbd.ca.gov/consumer/com...ractice.html#6

2) Should I talk to my insurance company? This is all new to me, is there any action they can take? I have no grievance against the insurance company, the pediatrician failed to send in proper paperwork, hence the denial of standard service (checkups, vaccinations).

3) Because I'm paranoid, if I contact the medical board and the insurance company, will my daughter somehow be red flagged for future claims?
Old 09-23-08, 01:15 PM
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Originally Posted by MonkeyG View Post
Upon arrival, the receptionist admitted that due to standard paperwork that the pediatrician failed to complete on time with our insurance company, that all our claims were being denied.
Sounds like the situation was caused by the doc, who then hid and cried. I don't know about the legal action you can take, but I doubt I'd want to even bother with a irresponsible doctor like that anyway.
Old 09-23-08, 01:23 PM
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I don't think he abandoned your daughter, he just said you had to pay in full before seeing him. That doesn't sound like it would match the medical board thing
Old 09-23-08, 01:23 PM
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I would file a report, but other than that, I wouldn't let it get to me. Maybe not to the state, but the AMA or some ethics board.
Old 09-23-08, 01:24 PM
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in addition to the med board, you should also talk to your insurance provider. if the doctor has an e-mail, i would e-mail them your dissatisfaction with their service, if not, then send a certified letter with return receipt. be calm, polite, but firm. i would do that first.

reason being, you don't want this to turn into a he said she said situation.

Last edited by D.Pham4GLTE (>60GB); 09-23-08 at 01:33 PM.
Old 09-23-08, 01:28 PM
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Originally Posted by Bronkster View Post
Sounds like the situation was caused by the doc, who then hid and cried. I don't know about the legal action you can take, but I doubt I'd want to even bother with a irresponsible doctor like that anyway.
Yeah, when I was a kid, one doc didn't file properly with the insurance co and demanded that we pay the difference. THey even had the nerve to get a collections agency involved. Pretty much why I hate doctors' offices.
Old 09-23-08, 01:29 PM
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I'm giving myself some breathing room so that I can keep my anger in check.
Sounds like you're doing everything right, so far!

We've dealt with our medical insurance company several times with questions and problems, and they have been very nice and helpful with us.

That (evil) pediatrician was denied payment from the insurance company and they (the insurance company) know all about it. I'd call them and see what information they have on the situation, and what you need to do. They just might have some answers!

-Pablito Tres

Last edited by The Edit King; 09-23-08 at 01:32 PM.
Old 09-23-08, 01:45 PM
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PS!

The insurance company has actual 'evidence' of why the claims were denied (failure on the part of the doctor's office) and if the Doctor sends you a bill, I'd contest it in a Heartbeat if I were you.

It's not your responsibility to pay (when you already have insurance that would cover the bills) because of their mistake.

Under that logic, any Doctor could say to him or herself, 'I'm just not going to send the paperwork in on time and then I can charge the patient in full anytime I want.'

I'm no expert (far from it), but I believe you have legal protection here.

-Pableeno

Last edited by The Edit King; 09-23-08 at 01:47 PM.
Old 09-23-08, 01:48 PM
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I would absolutely inform the state medical board. This is malpractice and extremely unethical. I would make sure he knew that I was the one that did it too.
Old 09-23-08, 01:51 PM
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I have to agree with what was said so far.

1. Start going to a new pediatrician

2. Call the insurance company to find out their side of the story (you'll want to do this anyway in case the doctor starts to come after you demanding payment)

3. Send a certified letter to the pediatrician asking for a detailed explanation, telling them what you've been told by the insurance company and recapping their claim that it was their fault papers were not submitted properly (you'll want this, again, in case they try to come after you for payment).

If you're still not satisfied...

4. Write a complaint to the BBB, state medical board, or whomever else handles these sorts of things. The worst case is that the doctor did nothing wrong, and these agencies just throw away your complaint. But in the meantime, at least you feel better and if some law or regulation was broken, the doctor will have to answer to the appropriate board.
Old 09-23-08, 01:51 PM
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Thanks everyone for your advice. To clarify, I'm not looking to pursue any legal action. Not worth my time and money. I just feel that it's so wrong to deny service once my wife and daughter are at the office and to not come out and explain it yourself.

I feel that somehow, Calfornia Medical Board or AMA as kvrdave brought up, should be given a heads up as to what this individual is doing.

DPham, yes I'm looking to contact my insurance provider although I'm not sure there's much they can do. The doctor just didn't fill out the proper paperwork, thus without proper paperwork, no claim. I don't understand how we can be billed for the doctor's mistake.

edit: Looks like a few more people posted while I was writing my reply. Thanks again everyone, you're actually helping me keep my anger in check while at the same time giving me really good advice! Matta, I'm going to go with your suggestion with those steps. Calling insurance company right after I post this.

Last edited by MonkeyG; 09-23-08 at 01:56 PM.
Old 09-23-08, 01:53 PM
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does your "old" pedi cover at times for your "new" pedi? if so, yeah, then definitely try and get him in trouble. that will serve you and your daughter quite well.
Old 09-23-08, 01:55 PM
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The doctor just didn't fill out the proper paperwork, thus without proper paperwork, no claim.
That's nails in the Doctor's coffin!

No claim - No charge!

(Well, that's what 'I' always say anyhow...)

They're responsible. Not you. You did nothing wrong.
Old 09-23-08, 01:56 PM
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Originally Posted by MonkeyG View Post

2) Should I talk to my insurance company? This is all new to me, is there any action they can take? I have no grievance against the insurance company, the pediatrician failed to send in proper paperwork, hence the denial of standard service (checkups, vaccinations).

File a Appeal with your insurance company


Because I'm paranoid, if I contact the medical board and the insurance company, will my daughter somehow be red flagged for future claims?
No.
Old 09-23-08, 02:02 PM
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It's funny. You go to school for 8-12 years and never once do you get a class about the "business" of practicing medicine. The amount of paperwork is mind-boggling. There are hundreds of insurance companies, HMOs, and government programs that all need paperwork filled out before they'll reimburse you. I can understand how your ped. dropped the ball.

That said, I'd never expect payment above the copay for my mistake. Some offices will re-submit the claims under the physician who signed the paperwork. I would suggest they do that, or dismiss the charges.
Old 09-23-08, 02:15 PM
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Originally Posted by MonkeyG View Post
Thanks everyone for your advice. To clarify, I'm not looking to pursue any legal action. Not worth my time and money. I just feel that it's so wrong to deny service once my wife and daughter are at the office and to not come out and explain it yourself.

I feel that somehow, Calfornia Medical Board or AMA as kvrdave brought up, should be given a heads up as to what this individual is doing.

DPham, yes I'm looking to contact my insurance provider although I'm not sure there's much they can do. The doctor just didn't fill out the proper paperwork, thus without proper paperwork, no claim. I don't understand how we can be billed for the doctor's mistake.

edit: Looks like a few more people posted while I was writing my reply. Thanks again everyone, you're actually helping me keep my anger in check while at the same time giving me really good advice! Matta, I'm going to go with your suggestion with those steps. Calling insurance company right after I post this.
I don't think you have a leg to stand on as far as denying service. The office didn't deny you service. They just directed youo to a different doctor that your insurance approved. They didn't refuse to treat your daughter outright; they just said one of their doctors couldn't treat her.

I would probably basically just forget about it unless the doctor's office tries to collect from you. But I would definitely call your insurance provider, voice your disapproval to the doctor and get an explanation from her, preferably in writing so that you have something to cover your ass if they do try to collect.
Old 09-23-08, 02:15 PM
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Quick update: I spoke to my insurance company. Their side of the story, our pediatrician either thought she was or was claiming she was in-network. Turns out she's not. She has no national contract with my insurance provider hence she is regarded as out-of-network. Therefore deductibles are now kicking in so she now wants to bill us for the deductibles.

Oddly enough, after the phone call I went online to my insurance providers website and type in her name, she shows up as in-network?!

I'm going to call the pediatrician's office next, they are closed noon to 1:30 so I'll have to wait for them to come back from lunch.

Last edited by MonkeyG; 09-23-08 at 02:18 PM.
Old 09-23-08, 02:32 PM
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1) Print out the website page showing in-network status. That is your smoking gun.

2) Ask to meet with the doctor's office manager. Present the information and offer that they accept your copays as full payment since they screwed up.

or

3) Ask your doctor to do an "adhoc" insurance agreement where he agrees to be paid in-network rates and the insurance company agrees to treat the relationship as an in-network (no out-of network deductibles). This can be done in the form of a letter agreement between the doc and the insurance company. The insurance company will know how to do this.
Old 09-23-08, 02:51 PM
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Originally Posted by MonkeyG View Post
Quick update: I spoke to my insurance company. Their side of the story, our pediatrician either thought she was or was claiming she was in-network. Turns out she's not. She has no national contract with my insurance provider hence she is regarded as out-of-network. Therefore deductibles are now kicking in so she now wants to bill us for the deductibles.

Oddly enough, after the phone call I went online to my insurance providers website and type in her name, she shows up as in-network?!

I'm going to call the pediatrician's office next, they are closed noon to 1:30 so I'll have to wait for them to come back from lunch.
keep records of who you talked to (pref. full name and extension), and what was discussed and when. also, ask for them to send you a copy of the denial letter.

and make sure to keep good records, documenting everything, in the event that it does make it to collections, you want to have very solid evidence. the money owed is only one thing - the hit on your credit report could hurt you a lot more.
Old 09-23-08, 02:56 PM
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Originally Posted by MonkeyG View Post
I just feel that it's so wrong to deny service once my wife and daughter are at the office and to not come out and explain it yourself..
I don't want to come off as an a-hole, but as previously stated:

They were not denied, they could pay cash. Unfortunately, the doctor did not submit paperwork with that insurance carrier - thus could no longer do business with them (for what ever reason).

You have a CHOICE - go somewhere else, or pay cash.

The Doctor went to medical school to deal with illness - not to become a customer service rep. So they have no reason to come out and meet with your family (now this may not be the best decision, and may cost them a customer, but it is their decision)

People need to realize that certain people are fantastic artisans, craftsman, thinkers, healers.... but not great businessmen! That is why some businesses do not last - that is why there are people like me, to help support the core product / service so that they can stay in business, and not let poor customer service, rude employees, or a laps in paperwork erode their customer base.
Old 09-23-08, 03:33 PM
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Originally Posted by MonkeyG View Post
In my mind, I think it's unethical to refuse to see my daughter due to a mistake in paperwork on her part!
Well, maybe you shouldn't have your newborn daughter filling out important paperwork then!
Old 09-23-08, 03:35 PM
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Originally Posted by CPA-ESQ. View Post
I don't want to come off as an a-hole, but as previously stated:

They were not denied, they could pay cash. Unfortunately, the doctor did not submit paperwork with that insurance carrier - thus could no longer do business with them (for what ever reason).

You have a CHOICE - go somewhere else, or pay cash.

The Doctor went to medical school to deal with illness - not to become a customer service rep. So they have no reason to come out and meet with your family (now this may not be the best decision, and may cost them a customer, but it is their decision)

People need to realize that certain people are fantastic artisans, craftsman, thinkers, healers.... but not great businessmen! That is why some businesses do not last - that is why there are people like me, to help support the core product / service so that they can stay in business, and not let poor customer service, rude employees, or a laps in paperwork erode their customer base.
You hate babies don't you?




j/k
Old 09-23-08, 03:40 PM
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I've heard of doctors who decide that certain insurance companies pay them so little for their time that it's not worth accepting that insurance. They stop accepting patients who are carried by that insurance company.

Does your insurance company pay pediatricians below their expenses?
Old 09-23-08, 03:45 PM
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Attach a dowry to her, imo
Old 09-23-08, 04:13 PM
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Originally Posted by bunkaroo View Post
You hate babies don't you?

Not a huge fan... I like them when they are able to do yard work / get you stuff from the kitchen.

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