Is it a fraud to waive copay and charge a lot to insurance company?
25 April 2014, 10:40 PM
I and my family moved to US two years ago and got confused by the health insurance. Our plan is PPO, individual OON deductible is $300. Last few months I went to an acupuncture for few times, the acupuncturist waived my copay and deductible, so I didn't pay anything.

Few days ago I got EOB from insurance company and found the acupuncturist charged a lot for a visit (~$650), and the claims payment was ~$450. Did it mean the insurance company paid $450 for me? I was told by acupuncturist that if I pay by cash, it would be ~$70, so my questions are:

1. is it normal to charge ~$650 for 1-hour acupuncture?
2. is it legal the acupuncturist charged much more to insurance company?
3. Is it my responsibility to report as fraud? I am not even sure if it's fraud. If it is and I don't report, will I be sued by insurance company?

Thanks for any answers.  
Votes: 150

Yes. The doctor is breaking his contract, by waiving the copayment - unless he is actually paying the copayment on your behalf.

1. Yes, it's normal for any medical provider in the USA, to artificially inflate the rates he charges, when he bills the insurance company. It is one of the major problems with our medical system here.
2. Yes. He can charge anything, and he can charge different people - or different insurance companies - different amounts. There are NO regulations at this time, regarding what medical providers can charge.
3. You can tell your insurance company that your copayment was waived - that's the only fraud I see here. Of course, your provider can then come back and bill you for it, and call it an "error" on his part, which is what I see happening.
Meta Analysis
A long question with some complicated concepts. The question deals with monetary issues, but the question tone is natural. The question isn't very well explained, but well formed.
A long answer and insightful. doesn't focus on cash, and the tone is tentative. The answer isn't very clear, and quite hard to understand.
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