I had cataract surgery done on both eyes. On both procedures, I elected to have restorative procedure done. My insurance didn't cover the restorative procedure, so I was required to pay for that in advance.

One surgery was done on 6/8/06 and the other on 8/24/06.

I received an invoice from the outpatient surgery center for the procedure done on 8/24, but not the one on 6/8. I received a notice from Blue Cross that I am only responsible for x amount of dollars which was over $300.00 less for each procedure that I had.

I called the billing phone number on the statement I had to request a refund. They processed the refund for the 8/24 procedure and I received the refund, but told me I had to contact the Outpatient Surgery Center for the other as their billing procedures had changed and another party was responsible for the billing on the 6/8 procedure.

So I went down to the Surgery Center with my paperwork to request a refund. The lady was very nice and said she had also requested the refund when I called about the 1st one.

Monday I had decided that enough time had lapsed so I called to follow-up. The lady told me she had gone on vacation for (2) weeks. I told her it was not my problem. This surgery was performed on 6/8/06 and if I had not requested a refund nothing would have been done. I told her if I didn't have the check in my hands by Friday, I would file a Small Claims Suit. I also informed her that I would definitely win that claim so in addition to the refund they would have to pay the court costs and fee for the Sheriff serving the papers.

I received the check yesterday (Friday) via Fed Ex.

So now I am made whole. But here is my question.

Would you report this clinic to Blue Cross, Consumer Affairs and Attorney General. I am positive that had I not checked the papers from Blue Cross and compared to the billing and the payment I made by credit card, then requested a refund, absolutely nothing would have been done. They would have kept an extra $600.00. I wonder how many other patients they have done this to and then didn't refund the difference.

Yes, I would. It is always frustrating when it comes to medical bills and insurance.

Me probably not. I received a check from the doctors office for one of my DS that we had overpaid. Now he hasn't been to this clinic for 18 months. Maybe there is a time frame for overpaying and refunding. They may allow you to carry a credit for so long. By the way, we had BCBS when we overpaid.

Off topic, but can I ask what "restorative" procedure you had done?

I believe restorative is relatively new. Rather than just correct the near sight or far sight, it corrects both.

Do you mean that you now no longer need glasses?

Wow, that would be really wonderful.

As for myself, the only times I now wear glasses are sitting at a computer and reading a menu in a dark restaurant. And the glasses I now use are just those cheap reading glasses I bought at a pharmacy.

I say go for it.

I'm editing to add that before these surgeries, I was wearing blended glasses. (tri focals)

No, I wouldn't report them.

I deal with Patient Accounts people all day long (for my job), and they have a rough job of dealing with insurance. Each insurance is different and requires different things, and getting an overpayment processed for pay back is a sometimes long and difficult process. It sounds like that the accounts dept. just let your account slip through the cracks. I seriously doubt it was intentional---it sounds like the medical provider had a change in staff or a change in their billing company. Crap happens and sometimes it is an HONEST mistake.
You have your money now, I say let it go.

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Mental that one, I'm telling you. ---Ron Weasley, "Harry Potter and the Chamber of Secrets"

I also work in medical billing. Let it go. Do you also know that your paperwork comes to you from the insurance companies 2 to 3 weeks before the check comes to the doctor many times? Also, the procedure you had done is very new and it could very well be that the billing is new. The insurance copanies do not tell the doctors and surgery centers the exact dollar amount they will pay ahead of time, especially with new procedures. I know, in Massachusetts, there is no set amount. Each insurance compnay is different and I do not know until the check comes, so I have to estimate, based on other insurance companies. Why is everyone so hot to turn doctors over to the attorney general etc? We are human, we make errors and most often it is the insurance company who ties our hands. Realx and let it go!

I realize that I had a new procedure and the surgery center might have known the amount of my required co-pay. However, if the billing company is going to have me pay a higher amount until they have determined the actual amount, they should return the overage in a timely manner. I am sure had there been a shortfall in what they received, they would have immediately come after me for the difference.

One of the surgeries was a year ago and the other almost a year ago. I am convinced that had I not checked my paperwork and gone after them for the refunds, they never would have sent me a refund.

If I wanted to be petty, I could have asked for interest on my money they kept for so long. They have probably earned interest on it during the time they had it.

My purpose in reporting this is to make sure that other patients who overpay and don’t pay attention to the billing get the refunds they deserve.
If the billing companies did nothing wrong, they have nothing to fear by my reporting this to the Insurance Company and the AG.

The best answer would be for you to pay the full amount, then get reimbursed by the insurance! That way no one makes any errors, no one is out any dollars and everyone is happy! But, I suspect that also would not be acceptable to you. I wish folks like you who are so quick to jump up and report people could just spend one day in a billing office. Until you have bene there, you can not possibly understand. How do you know others supposedly overpaid and where not refunded? What proof do you have? Despite the fact that the surgeries were a year ago, when was the doctor acutally paid (money in his bank account)? Do you have deductables etc that could of made your payment different from anyone else? Why do you say co-pay? Most insurances do not have a copay in a surgery center, does that make your amount different from anyone elses? The extra amount you paid is because the insurance considers the bifocal lens to be a luxury. The difference has nothing to do with copays. Before you go running to the AG, go to the billing company, sit down and ask for a expaination of the circumstances. You may be surprised!

Yeah...they may not have anything to fear, but it sure will make life difficult if the AG decides to do an investigation because of your complaint. Oh, and if you report to BCBS and BCBS decides to no longer accept them as a PPO, then EVERYONE will have to pay up front, then file the insurance themselves and wait for BCBS to reimburse them!

A medical provider accepting your insurance and doing the billing for you is a courtesy--it is not mandatory, by any stretch of the imagination!

Seriously, it sounds like a HUMAN ERROR that was corrected! People make mistakes. I do not for one minute believe that they intentionally kept your money!

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Mental that one, I'm telling you. ---Ron Weasley, "Harry Potter and the Chamber of Secrets"

You suspect wrong. That would have been perfectly acceptable.


I called it co-pay because that is the amount I was required to pay for that particular procedure. You may call it what you want. It’s all the same. Insurance pays a certain amount – I am required to pay a certain amount. If you want to nit pick over semantics, that is fine with me.

I do not know for sure whether or not others have overpaid. But I suspect they have since I had the same problem with both surgeries. I paid identical amounts up front and the insurance company covered identical amounts for both procedures. I did not receive a refund for either overpayment until I requested it.

But since I have no way of determining whether or not this has been happening to others (but suspect it has been) I feel by reporting it, hopefully, they will have to produce their records to the insurance company and/or AG or any other watchdog agency.

not nitpicking, if you are going to report this agency to the AG, BCBS and others, please at least use the proper terminology. It is NOT your copay, it is the amount they are charging you over and above the insurance allowables, HUGE difference in the medical world. Or is it your copay? That makes your story entirely different, because they do know the exact amount of your copay ahead of time and it is gravely wrong for them to charge you more than your copay to begin with. Believe it or not, they can charge you anything they want over and above insurance payment for so called "luxury procedures". I bet they gave you a refund as a courtesy to keep the patient happy! I work for an ophthamologist and bill this procedure fairly regularly. The copay is not affected by the luxury procedure. The amount over and above the standard procedure is determined by the surgeon and he can charge whatever he likes. Check your insurance regulations before you make too many calls. Unfortunately, for the rest of you who could afford to pay the difference only for this procedure and enjoy the benefits, it is people like this poster who will make it necessary for you to pay out of pocket a few thousand per eye, file the correct paperwork and then wait weeks for your reimbursement.

And in closing, let me add, I am no different than you, I need every $$ I make. Anytime I see a billing error or overpayment in the patients favor, it is refunded to the patient immediately. I work hard, I have a home and family, I need my $$. I am honest. I treat you the same as I want to be treated. If your doctor or surgery center is expecting their employees to break the law, then I say RUN from that doctor as fast as you can. The doctor or surgery center would be the only one who profits from what you say happened. The employee who is just trying to do their job does not and can not in any way. Remember, you are acusing these people of fraud and theft, a very serious accusation. Be sure you can back up your accusations before you report them for breaking the law. How long have they been in business? They would not be for long if they were stealing from their patients. Also, you did not answer my first question. What was the date the doctor/surgery center recieved the actual payment? And if I remember correctly, the amount the insurance says you may be charged, normally that is the amount IF YOU DID NOT agree ahead of time to pay the higher difference.

“Believe it or not, they can charge you anything they want over and above insurance payment for so called "luxury procedures". I bet they gave you a refund as a courtesy to keep the patient happy!”

You purport to be an expert on this subject. So get your facts straight. At least in the case of Blue Cross, when medical suppliers sign up with Blue Cross, they are required to accept the amount that Blue Cross sets. No more than that.

“not nitpicking, if you are going to report this agency to the AG, BCBS and others, please at least use the proper terminology. It is NOT your copay, it is the amount they are charging you over and above the insurance allowables, HUGE difference in the medical world. Or is it your copay? That makes your story entirely different, because they do know the exact amount of your copay ahead of time and it is gravely wrong for them to charge you more than your copay to begin with.”

I now have the “Explanation of Benefits” from Blue Cross in front of me. Under a column called “Coinsurance Copayment Amount” is an amount of $xxx. So, if Blue Cross calls this a copayment, I will accept that whatever you would like to call it. Also, on this Explanation of Benefits it states “It is your responsibility to pay: $xxx.xx It is not your responsibility to pay: $x,xxx.xx. I do believe this makes it quite clear. Therefore, it is not true that they gave me a refund as a courtesy to keep me happy.“

Unfortunately, for the rest of you who could afford to pay the difference only for this procedure and enjoy the benefits, it is people like this poster who will make it necessary for you to pay out of pocket a few thousand per eye, file the correct paperwork and then wait weeks for your reimbursement”

If you’re trying to give me a guilt trip for insuring that these people only collect the correct amount for this procedure, it won’t work. I feel I am doing a better service to people for having these people checked out so that patients are not paying $600.00 than they should have.

“Remember, you are acusing these people of fraud and theft, a very serious accusation. Be sure you can back up your accusations before you report them for breaking the law”

I was not accusing these people of fraud and theft. It certainly could have been a legitimate mistake on their part. But I want to make sure they don’t repeat this.

I have no idea when the checks were received since they certainly don’t open their books to me. However, again in looking at the “Explanation of Benefits” from Blue Cross, one has an “Issue Date” of July 28, 2006 and the other has an issue date of April 17, 2007. I assume these are the dates the checks were issued to the provider. Certainly the provider should have discovered the overpayment on the July 28, 2006 issue. I am certain that had it been a shortfall in payment to them, I would have heard from them a long, long time ago.

I am not following your story then. There are a couple of possible legal scenarios here and apparently you can not descirbe correctly the circumstances. When a doctor/surgery center signs a contract with a insurance company to "be a participating provider" they agree to accept the insurance companies allowables for COVERED SERVICES. The patient has a copay (you are correct) and the insurance company pays the rest. The amount the patient pays can not be any higher than the copay. In the case of your lens, the bifocal part is not a COVERED SERVICE. The doctor has no obligation to the insurance company regarding pricing of the bifocal expenses because it is considered a luxury item. They are only obligated to honor the pricing of the standard lens. What the doctor charges over and above the standard is his perogative. The same holds true for any additional surgery expenses. The amount you pay for the "luxury" feature has nothing whatsoever to do with coinsurance/copay amounts. I am certain that your doctor charged you three hundred dollars per eye for the non covered bifocal feature of your lens. That is a reasonable charge for the extra feature. It sure sounds to me like someone in his office screwed up the billing, was trying to make you happy and gave you the refund in error. If this was the office where I work, it would be investigated internally, giving the circumstances you have told here, and probably you would be balance billed for the 300.00 and the employee who issued the refund would be interviewed. I am not trying to give you a guilt trip, I am stating a fact. This is the reason so many doctors will not balance bill luxury, non covered items. The consumer does not understand insurance and how it works and the doctor loses. The doctor told you they switched billing companies and the second eye was paid over one year later. This tells me the doctor did have some type of problem with billing, switched companies and is doing the best they can to correct a problem.

OH ho, not so little grasshopper! ONLY if a medical provider agrees to be a preferred provider per BCBS contract do they have to accept whatever BCBS pays as payment in full.

They can accept BCBS and file for you, but they do not have to accept that as payment in full if they are not preferred providers/in network providers or contracted with BCBS. A provider filing YOUR claim for YOU is a courtesy. You are not entitled to you, it's not automatic and some places only file for certain insurances!

The only exception to this rule is Medicare. If a Drs office accepts Medicare they LEGALLY cannot bill the patient for the balance. And in most states the same is true with Workers Compensation. If a provider sees a patient and agrees to see them as it pertains to a work comp injury then they have to accept the fee schedule payment as payment in full and cannot bill the balance to the patient.

I sincerely suggest you put on your big girl panties and move on with life! At the very least before you start reporting people for illegal activities, please go to the BILLING office and speak to someone there and find out what happened with your account!

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Jesus love me--you he only tolerates!

“OH ho, not so little grasshopper! ONLY if a medical provider agrees to be a preferred provider per BCBS contract do they have to accept whatever BCBS pays as payment in full.”

I stand corrected on that one. In my case, the provider is a “preferred provider per BCBS contract”. Also stated on the “Explanation of Benefits” from Blue Cross – “This is the amount in excess of the allowed expense agreed upon by this provider. The member is not responsible for this amount”

“In the case of your lens, the bifocal part is not a COVERED SERVICE. The doctor has no obligation to the insurance company regarding pricing of the bifocal expenses because it is considered a luxury item. They are only obligated to honor the pricing of the standard lens. What the doctor charges over and above the standard is his perogative. The same holds true for any additional surgery expenses. The amount you pay for the "luxury" feature has nothing whatsoever to do with coinsurance/copay amounts. I am certain that your doctor charged you three hundred dollars per eye for the non covered bifocal feature of your lens. That is a reasonable charge for the extra feature. It sure sounds to me like someone in his office screwed up the billing, was trying to make you happy and gave you the refund in error. If this was the office where I work, it would be investigated internally, giving the circumstances you have told here, and probably you would be balance billed for the 300.00 and the employee who issued the refund would be interviewed.”

Well Snow, once again I suggest you check your facts. Billing as per Surgery Center statement:

Extracapsular Cataract Removal $x,xxx.xx
Restore Lens x,xxx.xx
Patient Payment (xxx.xx)
Approved Discount (xxx.xx)

So it appears that this procedure was billed correctly. No screw up on billing. Restore lens included in insurance coverage. That is what was submitted by Surgery Center to BC.


And since the (2) posters who work in this field are so adamant about not reporting this, it has convinced me to call BC. Let BC check into this and do what they feel is right.

I also hope others will check all medical billings and go after any overpayments they might have made.


P.S. My big girl panties are on.

I don't work in medical billing. My job does require me to work WITH medical billers/patient accounts all day.

I do agree that everyone should check their EOBs and Itemized statements from their provider to make sure they are not billed incorrectly and that all insurance payments have been taken in account.

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Jesus love me--you he only tolerates!

have a ball! just get your story straight before you call, use the correct terminology. Be sure to let us know how it works out. Also, please remember, you are accusing the employees of fraud, no matter what spin you put on it. Please make sure you can back up your accusations. If a patient accusses one of our employees of doing something illegal and has not had the courtesy to sit down with someone in our office for an explaination, we ask them to leave the practice. Those are not the type of patients we want.